1. The document discusses the approach and management of polytrauma patients. It outlines the concepts of trauma care including the ATLS philosophy and damage control surgery. 2. Polytrauma is defined as two or more body regions with signs of systemic inflammatory response syndrome (SIRS). The metabolic response to trauma occurs in two phases - the ebb phase which conserves energy and the flow phase which mobilizes resources. 3. Management principles include organized team approach, treatment before diagnosis, and frequent re-examination. The primary and secondary surveys follow the ATLS protocol to address airway, breathing, circulation, disability, and exposure.

1. APPROACH & MANAGEMENT OF
POLYTRAUMA
Dr.K.R.Dharmendra.,
M.S[Gen.Surg].,D.N.B[Gen.Surg].,
AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT

2. OUTLINE
 Concepts of trauma care
 Principles of trauma management
 ATLS Philosophy
 Damage control surgery
 Future directions

3. EPIDEMIOLOGY
 Trauma—commonest cause of
death between 1-40
 By 2020, injuries—third leading
cause of death

4. Definition of Polytrauma
 2 or more body regions with SIRS

5. SIRS
 2 out of 4 signs
Tachycardia >90 beats/min
Tachypnoea >20 breaths/min
Pyrexia >38 c[or hypothermia <36 c]
WBC >12000/mcL or <4000/mcL

6. SEPSIS
SIRS with a proven infective
source

7. MODS
Severe Sepsis
CVS
RS
Kidney
Liver
Coagulation

8. METABOLIC RESPONSE TO
TRAUMA
TWO PHASES
EBB PHASE
Role: conserve volume & energy
for recovery & repair
FLOW PHASE
Role: mobilization of body
resources

9. EBB PHASE
 Lasts for 24-48 hrs
 Characterised by
 Hypovolaemia
 Decreased BMR
 Reduced cardiac output
 Hypothermia
 Lactic acidosis

10. FLOW PHASE
Corresponds to SIRS
Tissue oedema
Increased BMR
Increased cardiac output
Leucocytosis, Raised body temperature
Increased oxygen consumption
Increased gluconeogenesis
 Catabolic – 3-10 days
 Anabolic - weeks

11. METABOLIC RESPONSE TO TRAUMA

13. PHARMACOLOGICAL
IMMUNOMODULATION

14. IMMUNO NUTRITION

15. IMMUNO
SUPPRESSION
• Epidural anaesthesia
• Statins
• B blockers
• Tranexamic acid

16. GRADES OF HAEMORRHAGE

17. REVISED TRAUMA SCORE

18. “WELL BEGUN IS HALF
DONE”
• Initial assessment & management
is critical in decreasing morbidity
& mortality
• Aids recovery

19. THE GOLDEN HOUR

20. TRIMODAL DEATH
DISTRIBUTION

21. TRIMODAL DEATH
DISTRIBUTION

22. PRINCIPLES OF TRAUMA
MANAGEMENT
• Organised team approach
• Assumption of most serious injury
• Treatment before diagnosis
• Thorough examination
• Frequent examination

23. TRIAGE
• In French, triage
means “to sort”
• Goals:
• To identify the high
risk injured patients
• To channelise the
transport of
patients to
appropriate centres

24. 3 PHASES OF
TRIAGE
• Pre hospital Triage
• At the scene of trauma
• On arrival at hospital

25. MULTIPLE CASUALTIES
• The number &
severity <
Facility of the
center
• Priority is for
life threatening
injuries

26. MASS CASUALTIES
• The number &
severity >
Facility of the
centre
• Priority is for
best chance of
survival, least
expenditure

27. COMMUNICATION
• Co ordination between pre
hospital & hospital care
• Timely preparation & mobilization
of trauma team
• Hemodynamic instability is also
informed

28. HAND OVER
• Ambulance driver to Trauma
team leader verbally
MIST
• Mechanism of Injury
• Injuries suspected
• Vital signs
• Treatment en route to hospital

29. TRAUMA TEAM
• For better triage & care
• Registrars from
ED
ICU
Surgery
Radiology
Anaesthesiology
• Theatre staff
• Spokesperson

30. ROLES SPECIFIED
• Team Leader—Registrar from ED or ICU
Airway Doctor
• Plans interventions & treatment in
consultation with Surgical Registrar
[Traffic Controller & Information Collator]
• Surgical Registrar—Circulation Doctor
Procedure Doctor
Secondary Survey

31. ATLS PHILOSOPHY
• Primary Survey & Resuscitation
• Secondary Survey
• Definitive Care

32. PRIMARY
SURVEY

33. PRIMARY SURVEY
• A—Airway Maintenance &
Cervical spine protection
• B—Breathing & Ventilation
• C--- Circulation & Haemorrhage
Control
• D--- Disability: Neurological status
• E--- Exposure & Environment
protection

34. C-SPINE PROTECTION
Assume a cervical spine injury
in any patient with multisystem
trauma, especially with an
altered level of consciousness,
or a blunt or penetrating injury
above the level of the clavicle

35. PHILADELPHIA COLLAR
• 35

37. Airway Management
Aims
• When is the airway potentially
threatened?
• When is the airway compromised?
• How do you treat and monitor?
• What is a definitive airway?

38. Predisposing Conditions
• Coma
• Aspiration
• Maxillofacial trauma
• Neck injury
• Haematoma
• Laryngeal injury
• Thoracic inlet penetrating injury

39. Signs of Airway Obstruction :
"Look"
• Agitation
• Poor air movement
• Rib retraction
• Deformity
• Foreign material

40. Signs of Airway Obstruction :
"Listen"
• Speech? "How are you?"
Hoarseness
• Noisy breathing
• Gurgle
• Stridor

41. Signs of Airway Obstruction :
"Feel"
• Fracture crepitus
• Airway structures in neck
• Tracheal deviation
• Haematoma

42. AIRWAY RESUSCITATION
• Suction
• Chin lift
• Jaw Thrust
• Oral airway
• Definitive Airway

43. • POLY5-34

44. CHIN LIFT

45. JAW THRUST

46. When do you intubate the patient?
• This is the definitive airway
• Brain injury with GCS <8
• Severe multi system injury or
haemodynamic instability
• Facial burns or inhalational injury
• Inability to closely monitor during
ongoing resuscitation & investigation
[ angio&CT]
• Uncooperative or combative behavior

47. Cricothyroidotomy
INDICATIONS
• Trauma causing oral, pharyngeal
or nasal haemorrhage
• Foreign body obstruction
• Maxillo facial injuries

48. Technical considerations
• No surgical Cricothyroidotomy
below 12 years
• A permanent tracheostomy within
24 hrs
• More than 2 days—higher risk of
glottic stenosis

49. NEEDLE CRICOTHYROIDOTOMY

50. COMPLICATIONS
EARLY
• Bleeding
• False passage
• Subcutaneous emphysema
• Oesophageal perforation
• Vocal cord injury

51. LATE
• Infection
• Glottic & Subglottic stenosis
• Tracheo oesophageal fistula

52. BREATHING & VENTILATION
Abnormal Breathing : Look
• Cyanosis
• Decline in mental state
• Chest asymmetry
• Tachypnoea
• Distended neck veins
• Paralysis
• Chest wounds
• Flial segment

53. Abnormal Breathing : Listen
• I can't breathe!
• Stridor, wheezing
• Decreased breath sounds

54. Abnormal Breathing : Feel
• Surgical emphysema
• Chest tenderness
• Trachea deviated
• Percussion & Auscultation

55. DEADLY DOZEN THREATS FROM
CHEST INJURY
Immediately Life Threatening
• Airway Obstruction
• Tension Pneumothorax
• Pericardial Tamponade
• Open Pneumothorax
• Massive haemothorax
• Flial Chest

56. Potentially Life Threatening
• Aortic Injuries
• Tracheo bronchial Injuries
• Myocardial Contusion
• Rupture of Diaphragm
• Oesophageal injuries
• Pulmonary Contusion

57. SEALING OF OPEN WOUND

58. Tension Pneumothorax
• Not a radiological diagnosis; only
clinical
• Put a needle in 2nd ICS in MCL
• Later ICD at 5th ICS in mid axillary
line

59. TENSION PNEUMOTHORAX

60. HAEMOTHORAX
• ICD
INDICATIONS OF THORACOTOMY
• Initial 1500 ml
• 200 ml for 3 consecutive hours

61. FLIAL CHEST
• Rib fractured at 2
different places
• Paradoxical chest
movements
• Underlying lung
contusion
• Positive pressure
ventilation
• Rarely surgical
fixation is necessary

62. CIRCULATION & HAEMORRHAGE
CONTROL
• Surgical Registrar & procedure
nurse apply pressure bandage to
open wounds
Signs:
• Deteriorating conscious level
• Pallor
• Rapid , thready pulse

63. Is the heart beating?
• Is there serious external
bleeding?
• Does patient have radial pulse?
• Absent radial = systolic BP < 80
• Does patient have carotid pulse?
• Absent carotid = systolic BP < 60

64. Is patient perfusing?
• Cool, pale, moist skin
• Capillary refill > 2 sec
• Restlessness, anxiety,
combativeness
If internal hemorrhage, quickly
expose, palpate abdomen, pelvis,
thighs

65. THE STRATEGY
• Primary Haemorrhage Control and
timely surgical intervention rather
than Overaggressive Fluid
Resuscitation
[ Permissive Hypotension ]

66. THE PROCEDURES
• IV access by procedure doctor
• 2 wide bore cannula - 14 G or 16 G
• Scalp bleeding—running locked
sutures
• Open fractures—direct pressure,
reduction& splinting
• No blind clamping of vessels
• Angiography & embolisation

67. CAUSES OF MAJOR BLEEDING
MAJOR BLEEDING -THE BIG FIVE
• EXTERNAL
• THORACIC
• PELVIC
• LONG BONES
• ABDOMEN

68. FLUID THERAPY
• Crystalloid fluid is preferred
• Class 3 &4 shock—colloid
fluid advised
• Bolus of 1 litre of RL given

69. 3 RESPONDERS
• Rapid Response
Be careful, these patients may still
require surgery and may become "unstable"
again!
• Transient Response
Stop the bleeding!
• Minimal Response
Remember the "Big 5"!
Go to the operating theatre!

70. Investigations for tissue perfusion

71. Transfusion Guidelines

72. Transfusion Guidelines
• HCT < 21
• Lesser HB trigger in
Asymptomatic patients
• Higher HB trigger in severe CV
diseases

73. Why RL is preferred over NS
• RL gives a hypercoagulable state
• NS causes hyperchloremic acidosis
• Significant difference in HCT
• NS decreases FVIIa & FVIIa- Tissue Factor
Complex
• But in Head injury, RL may cause cerebral
oedema
• In patients taking metformin, chance of
metabolic alkalosis is there if you use RL

74. METABOLIC ACIDOSIS
• Decreases Cardiac contractility
• Decreases effectiveness of circulating
catecholamines
• Inhibits propagation phase of
thrombin generation
• Accelerates Fibrinogen degradation
• Hyperchloremia causes renal
vasoconstriction- decrease in GFR

75. DISABILITY & NEUROLOGICAL
EXAMINATION
• Level of Consciousness = Best
brain perfusion sign
• Use AVPU initially
• Check pupils
• Eyes are the window of the CNS

76. Brief Neurologic Examination
• A–Alert
• V –Responds to Vocal stimuli
• P–Responds to Painful stimuli
• U–Unresponsive
More detailed evaluation
-during the Secondary Survey

77. Decreased LOC
• Brain injury
• Hypoxia
• Hypoglycemia
• Shock
• Never think drugs, alcohol, or
personality first

78. GCS
EEYYEE OOPPEENNIINNGG VVEERRBBAALL MMOOTTOORR
SSppoonnttaanneeoouuss 44 OOrriieenntteedd 55 OObbeeyyss 66
VVeerrbbaall 33 CCoonnffuusseedd 44 LLooccaalliisseess 55
PPaaiinn 22 WWoorrddss 33 WWiitthhddrraawwss 44
NNoonnee 11 SSoouunnddss 22 DDeeccoorrttiiccaattee 33
NNoonnee 11 DDeecceerreebbrraattee 22
NNoonnee 11

79. DISABILITY INTERVENTIONS
• Spinal cord injury
–High dose steroids if within 8 hours
• ICPmonitor-Neurosurgical consultation
• Elevated ICP
–Head of bed elevated
–Mannitol
–Hyperventilation
–Emergent decompression

80. Exposure&Environmental protection
• Complete disrobing of patient
• Logroll to inspect back
• Rectal temperature
• Warm blankets/external warming
device to prevent hypothermia

81. Always Inspect the Back

82. PAUSE & CHECK
• Are all immediately life-threatening
injuries
identified?
• Is all monitoring in place?
• Investigations ordered?
• Analgesia?
• Relatives informed?
• Non-essential team
members disbanded?

83. The well practiced
trauma team
should aim to
complete the
primary survey in
less than 10
minutes

84. Adjuncts to Primary Survey
• ECG monitoring
• Urinary and Gastric Catheters
• Monitoring
• X-rays and Diagnostics Studies

85. Monitoring
1. Ventilatory rate and ABG
• Monitor the adequacy of respiration
• Confirm the ETT location
2. Pulse oximetry
Measure of oxygen saturation of Hb
• Should not be placed distal to the
blood pressure cuff
3. Blood pressure

86. X-rays and Diagnostics Studies
• Chest x-ray AP
• Pelvis AP
• Lateral C-spine
• DPL or FAST
• Films can be taken in resuscitation
area, usually with portable x-ray
• Should not interrupt the
resuscitation process

87. INDICATIONS FOR ICU
ADMISSION
Requirement for:
• Airway protection and mechanical
ventilation
• Cardiovascular resuscitation
• Severe head injury
• Organ support
• Correct coagulopathy
• Invasive monitoring

88. SECONDARY
SURVEY

89. SECONDARY SURVEY
• Does not begin until the primary
survey (ABCDEs) is completed
• Complete history
• Head-to-toe evaluation
• Reassessment of all vital signs

90. HISTORY
A - Allergy
M- current Medication
P- Past illness and operation
L- Last meal
E- Event and Environment
related to the injury

91. A Complete “Head to Toe’
examination
• HEENT: scalp, eyes, ears, face, throat
• Neck: distended neck veins, trachea midline, posterior
midline deformity
• Chest wall: flail segment, breath sounds
• Abdomen: scaphoid or distended, tender
• Pelvis: stable or unstable
• Genitourinary: blood, bruising
• Rectal: tone, blood
• Back: spinal deformity, exit wounds
• Extremities: deformity, pulses
• Neurologic: GCS,feels all four/moves all four

92. LOG ROLLING
• 4 Persons required
• 1 - Spinal inline traction
[anaesthesiologist]
• 2 -Torso
• 3- Pelvis & Lower limb
• 4- Detailed examination of back

94. EXAMINATION OF BACK
• Examine entire spine
• Any penetrating injury or exit
wound
• Appropriate Dressing
• Palpation of posterior chest
wall
• Percussion & Auscultation of
post.chest

95. SECONDARY SURVEY
‘Tubes and fingers in
every orifice’

96. Adjuncts to the Secondary Survey
• Further investigation for specific
injuries after stabilising the patient
• x-ray spine and extremities
• CT scan
• contrast urography and angiography
• Transesophageal ultrasound
• Bronchoscopy
• Esophagoscopy

97. RE-EVALUATION
• Continuous monitoring of vital signs, Hct
• urinary output: adult keep > 0.5 mL/kg/hr
children keep > 1 mL/kg/hr
• Arterial blood gas
• Cardiac monitoring
• Pulse oximetry
• End tidal CO2
• Relief of severe pain and anxiety
IV opiates and anxiolytics

98. DPL

99. INDICATIONS FOR DPL
• Equivocal abdominal sign
• Unexplained hypotension
• Impaired mental status
• Paraplegia or spinal cord
injuries

100. CONTRAINDICATIONS FOR DPL
Absolute contraindication
• existing indication for explore
laparotomy
Relative contraindications
• Previous abdominal operation
• Morbid obesity
• Advance cirrhosis
• Coagulopathy

101. CRITERIA FOR POSITIVE DPL
> 10 ml of gross blood in blunt trauma
• RBC count >100,000 /mm3 for blunt
trauma
• RBC count >10,000/mm3 for
penetrating trauma
• WBC count > 500/mm3
• Amylase > 200u/ml
• Smear show bacteria or enteric content

102. DPL

103. DPL
Advantages
• Fast
• Sensitive
• Can be performed while resuscitation
ongoing
Disadvantages
• Invasive
• Learning curve
• Not Organ specific

104. FAST

105. FAST
• Detect intra abdominal fluid
• Rapid, noninvasive, accurate,
inexpensive, can repeat frequently
• Indications same as DPL
• Factors that compromise its utility
are obesity, presence of
subcutaneous air, previous
abdominal operation

106. FAST

107. ADVANTAGES OF FAST
• Fast
• Noninvasive
• Can be performed while
resuscitation ongoing
• Can be very sensitive

108. DISADVANTAGES OF FAST
• Operator dependent
• Body habitus may limit
quality/sensitivity
• Organ aspecific
• Can’t detect Hollow viscous
and retroperitoneal injuries

109. Trauma Management

110. CARRY HOME MESSAGE
• Organised Team Approach
[There is no ‘I’ in TRAUMA]
• Initial Assessment & Management is the key
• Interferon –gamma, Epidural Anaesthesia &
Early enteral nutrition
• Appropriate Triage according to resources
• Communication is pivotal for better
preparation or Trauma Team

111. • ATLS Philosophy
• Primary Survey in 10 min
• C-Spine protection with
Philadelphia Collar
• Needle Cricothyroidotomy – Ideal
in emergency situations where
Intubation is not feasible
• Tension Pneumothorax is a clinical
diagnosis; Immediate needling
should be done

112. • Primary Operative Control of haemorrhage
is preferred over Overaggressive Fluid
Resuscitation – Permissive Hypotension
• No blind clamping of vessels
• Angio embolisation is an important tool in
controlling haemorrhage
• Fluid challenge of 1 L RL is preferred
• Serum lactate level & mixed venous
saturation are the most indicators of tissue
perfusion
• If HB<7 & HCT<21- Transfusion indicated

113. • Brief Neurological exam is enough initially
• Rule out organic causes for decreased
consciousness before thinking of drugs, alcohol &
personality
• Examination, Resuscitation & monitoring should
go hand in hand
• Head to Foot Secondary Survey is important to find
out the missed injuries; Done by Surgical Registrar
• “Tubes & Fingers in every orifice” –Theme of
Secondary Survey
• DPL & FAST come in handy in equivocal abdominal
signs & Unexplained Hypotension
• Damage Control Surgery is the weapon to tackle
the “Triad of Death”

114. TRAUMA @ AHIH
• Trauma Team
• Trauma Protocol
• Training of Personnel
• Learning of Procedures
• In house/On call Consultants

115. July 20 1969

116. • “From inability to Let well alone;
• from too much zeal for the new and
Contempt for what is old;
• from putting knowledge before Wisdom,
• science before Art,
• and cleverness before Common sense,
• from treating patients as cases,
• and from making the cure of the disease
more grievous than the Endurance of the
same,
• Good Lord, deliver us.”
--Sir Robert Hutchison

117. A
Dharmendra
Presentation