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Management of
polytraumatized patients
‘ The art of life Support’
BY
Hosam Mohamad Hamza, MD
Lecturer of General Surgery a...
What is trauma ?
Trauma is the study of medical problems associated with
physical injury.
Trauma is the 3rd leading cause of death in people aged 1-44
years, and a leading cause of disability.
WHO data suggest th...
Aetiology of trauma & Mechanism of injury
Penetrating traumaBlunt trauma
- Stabs
- Gunshots
- Bullets
- Motorvehiclecollis...
Trauma related mortality may be:
Late DeathEarly DeathImmediate death
20%30%50%%
days or weeks1st few hours
( golden hours...
Trauma-related mortality
Immediate
50%
Early
30%
Late
20%
Organized trauma team Organized trauma system
Management of trauma
I. Trauma Team
Patients with major trauma are best treated by a well-
organized trauma team.
Each team member should be as...
II. Trauma System
Recently, many protocols were introduced for management of
multi injured patients including :
ATLS → Adv...
severaltechniques used tomaintain life whenessential body systems are
not sufficiently functioning to sustain life unaided...
Advanced Trauma Life Support (A.T.L.S.)
In 1970s, an air crashlead to the death of the wife and serious injuries of
the th...
Triage
sift and sort
Normal clinical practice
Multiple-casualty incident
Mass casualties
Normal clinical practice: one doctor or nurse
and one patient. = Do everything possible for
every patient.
Multiple-casual...
Sift
1. Identify those most severely injured.
then
2) identify and remove:
the dead
the slightly injured
the uninjured
Sort
Categorise the most severely injured:
Serious wounds: resuscitation and
immediate action
Second priority: need surger...
Category I: Resuscitation and immediate
action
Patients who need urgent surgery – life-saving –
and have a good chance of ...
Category II: Need surgery but can wait
Patients who require surgery but not on an
urgent basis.
A large number of patients...
Category I for Airway; Category II for debridement
Category III: Superficial wounds
(no surgery, ambulatory treatment)
Patients with wounds requiring little or no surgery.
I...
Category IV: Very severe wounds
(no surgery, supportive treatment)
Patients with such severe injuries that they are
unlike...
Philosophy of ATLS:
“ Treat the lethal injuries first, then
re-assess and treat again ”
Components of ATLS:
Primary Survey...
Primary survey and
Resuscitation
identify and treat any life threatening condition.
it must be repeated any time a patient...
Lack of an airway is one of the few situations in medicine in which
seconds count.
Regarding the airway = assess, maintain...
* maintain:
* maintain:
* protect:
clearthe airwayif it becomes obstructed
* provide:
Indications of endotracheal entubation (ETE) in
patients with major trauma:
1.Apnea (as part of CPR).
2.Respiratory insuff...
Types :
-needle cricothyroidotomy
-surgicalcricothyroidotomy
?
Cricothyroidotomy:
more simple and faster than tracheostomy.
not suitable for children < 10 years.
needle cricothyroidot...
?
Cervical spine should be considered unstable until proved
otherwise by radiology (at least 3 views) esp. in:
*Altered le...
Having a patent airway is not necessarily associated with normal
respiration.
Abnormalrespiration after trauma may be :
a....
Assessmentof breathing :
1- Inspection :-
chest wall bulge or retraction.
chest expansion.
chest wounds.
respiratory rate ...
5- Pulse oximetry ( ?unreliable)
6- ABG sampling
7- Chest Xray
While reading a chest X
ray film, a good
trauma surgeon
sho...
Normal film Rt sided pneumothorax
Massive haemothorax pneumothorax
Flail chest Hypoxia
1- Rib fracture pain may cause the patient to hold
the chest still.
2- Pulmonary contusion (if present...
Pathophysiology
In the inspiratory phase, chest wall
collapses inwards forcing air out of
the bronchus of the involved lung
into the trach...
In the expiratory phase, chest wall
balloons outwards so that air expelled
from bronchus of the uninvolved lung
into enter...
This is a very insufficient form of
respiration, and the patient will die of
hypoxia and exhaustion if the condition is no...
Tension pneumothorax is MAINLY a clinical
diagnosis.
Do not wait for radiographs if suspecting classic
manifestations:
-ch...
Tension (Massive) hemothorax is defined
as 1500 mL of blood in the chest cavity .
Patient who continues to bleed (a flow o...
Failure of peripheral circulation (i.e shock) is a very common cause of
trauma-related death
causes of post-traumatic shoc...
* assess:
A. symptoms:
• thirst sensation.
• air hunger.
• coldness.
• Restlessness (in early
post-haemorrhagic state)
the...
Systemic signs of shock:
• oliguria:
(< 0.5-1 ml/kg/hour) due to:
- ↓ Renal Blood Flow
- ↑ ADH release.
• skin ( of extrem...
* estimate:
The amount of blood loss can be estimated as follows:
- clinically (table of the next slide).
- external blood...
Class I Class II Class III Class IV
Blood loss Up to 15% 15 – 30% 30 – 40% > 40%
Mental state Normal to
Anxious
Anx. to
Re...
* treat:
1- treatment of the cause (e.g. control haemorrhage)
2- replacement of losses.
3- monitoring.
* treat:
1- treatment of the cause (e.g. control haemorrhage):
• Cannon and colleagues (1923) first observed that attempts...
* treat:
1- treatment of the cause (e.g. control haemorrhage).
2- replacement of losses:
restore Circulating blood volume ...
* treat:
1- treatment of the cause
2- replacement of losses:
5- I.V. fluid administration:
IV fluids come in four differen...
Tonicity Osmosis Examples
ISOTONIC As plasma No or minimal
- normal saline (0.9% NaCl)
- dextrose5%
- ringers lactate: (Na...
• The ideal fluid to be used continues to be debated; however,
crystalloids continue to be the mainstay of fluid choice.
•...
Dynamic Fluid Response
• Shock status can be determined dynamically by the cardiovascular
response (HR, BP and CVP) to rap...
3- Monitoring:
The minimum standard for monitoring of a patient in shock is:
• Continuous HR & O2 sat. monitoring (ECG & P...
Base deficit and lactate:
• It is measured by serum lactate level and/or base deficit from ABG
analyses.
• Patients with a...
* causes :
head injury, shock , hypoxia and intoxication.
* assess :
AVPU method
Alert and responsive .
Vocal stimulus eli...
Response SCORE
Eye opening response Spontaneous 4
To voice 3
To pain 2
None 1
Best verbal response Oriented 5
Confused 4
I...
All clothes are removed using large sharp scissors.
Antihypothermic measures:
• Hypothermia in patient with bleeding leads...
Some cases may require transfer to another hospital
with higher facilities or to another department in the
same hospital. ...
Summary of the primary survey
Airway - Airway opened, airway obstruction treated, possible definitive airway
placed
Breath...
Secondary Survey
-starts once resuscitation efforts are underwent and
preliminary X rays have been evaluated.
-steps :
* e...
Definitive Care
* after identification of the cause & region of injury (after 2ry survey).
* Patients with multiple injuri...
hosam_hamza@ymail.com
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
Management of polytraumatized patients
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Management of polytraumatized patients

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Management of polytraumatized patients

  1. 1. Management of polytraumatized patients ‘ The art of life Support’ BY Hosam Mohamad Hamza, MD Lecturer of General Surgery and Laparo-endoscopy Minia School Of Medicine Minia –Egypt 2016
  2. 2. What is trauma ? Trauma is the study of medical problems associated with physical injury.
  3. 3. Trauma is the 3rd leading cause of death in people aged 1-44 years, and a leading cause of disability. WHO data suggest that 1 in 10 deaths worldwide is a result of trauma. Serious multi-system injuries occur in 10 -15% of (polytraumatized patients) PTP. Magnitude of the problem?
  4. 4. Aetiology of trauma & Mechanism of injury Penetrating traumaBlunt trauma - Stabs - Gunshots - Bullets - Motorvehiclecollision (50-75%) - Direct blows to thebody(15%) - Falling from a height (6-9%) Causes - Tissue tearing. - Thermal injury. - Missle injury - Crushing: direct application of a blunt forceto part of thebody. - Shearing: sudden decelerations applied across organs with fixed attachments. - Bursting: e.g. raised intraluminal pressure by abdominalcompression. - Penetration bony injuries generate spicules causing secondary penetrating injury. Mechanism of injury
  5. 5. Trauma related mortality may be: Late DeathEarly DeathImmediate death 20%30%50%% days or weeks1st few hours ( golden hours) soon or within minutesTime after injury -Sepsis. -Multi-organ failure (M.O.F.) obstruction.Airway- -disruption of mechanism.breathing failure.Circulation- injury.brainmajor- injury.cordhigh- airwaymajor- disruption. Causes Proper patient follow-up. Training about ABC resuscitation programs. Community education about trauma- preventing programs (seat belts, head protection,…etc) Prevention
  6. 6. Trauma-related mortality Immediate 50% Early 30% Late 20%
  7. 7. Organized trauma team Organized trauma system Management of trauma
  8. 8. I. Trauma Team Patients with major trauma are best treated by a well- organized trauma team. Each team member should be assigned a specific task or tasks so each of these can be performed simultaneously.
  9. 9. II. Trauma System Recently, many protocols were introduced for management of multi injured patients including : ATLS → Advanced Trauma Life Support. followedby: ATNC → Advanced Trauma Nursing Course. and more recently: PHTLS → Pre-Hospital TraumaLife Support.
  10. 10. severaltechniques used tomaintain life whenessential body systems are not sufficiently functioning to sustain life unaided pre-hospital care: advancedmedicalcare:
  11. 11. Advanced Trauma Life Support (A.T.L.S.) In 1970s, an air crashlead to the death of the wife and serious injuries of the three children of James Styner; an American orthopedic surgeon. An event that had forced him tointroduce a structured trauma management program which was soonadopted by The American College of Surgeons and developedthe Advanced Trauma Life Support (ATLS)protocol or EMST (Early Management of SevereTrauma) as known in the UK.
  12. 12. Triage sift and sort Normal clinical practice Multiple-casualty incident Mass casualties
  13. 13. Normal clinical practice: one doctor or nurse and one patient. = Do everything possible for every patient. Multiple-casualty incident: one doctor and many patients. = Triage, but still capable of dealing with all patients. Mass casualty: one doctor overwhelmed by casualties. = Triage, do what you can for the greatest number.
  14. 14. Sift 1. Identify those most severely injured. then 2) identify and remove: the dead the slightly injured the uninjured
  15. 15. Sort Categorise the most severely injured: Serious wounds: resuscitation and immediate action Second priority: need surgery but can wait Superficial wounds: ambulatory management Severe wounds: supportive treatment
  16. 16. Category I: Resuscitation and immediate action Patients who need urgent surgery – life-saving – and have a good chance of recovery. (E.g. Airway, Breathing, Circulation: tracheostomy, haemothorax, haemorrhaging abdominal injuries, peripheral blood vessels)
  17. 17. Category II: Need surgery but can wait Patients who require surgery but not on an urgent basis. A large number of patients will fall into this group. (E.g. non-haemorrhaging abdominal injuries, wounds of limbs with fractures and/or major soft tissue wounds, penetrating head wounds GCS > 8.)
  18. 18. Category I for Airway; Category II for debridement
  19. 19. Category III: Superficial wounds (no surgery, ambulatory treatment) Patients with wounds requiring little or no surgery. In practice, this is a large group, including superficial wounds managed under local anaesthesia in the emergency room or with simple first aid measures.
  20. 20. Category IV: Very severe wounds (no surgery, supportive treatment) Patients with such severe injuries that they are unlikely to survive or would have a poor quality of survival. The moribund or those with multiple major injuries whose management could be considered wasteful of scarce resources in a mass casualty situation.
  21. 21. Philosophy of ATLS: “ Treat the lethal injuries first, then re-assess and treat again ” Components of ATLS: Primary Survey identify what is fatal and treat it. Secondary Survey proceed todiscover all other injuries. Definitive Care develop a definitive management plan.
  22. 22. Primary survey and Resuscitation identify and treat any life threatening condition. it must be repeated any time a patient's status changes. Steps : (stepwise approach) history : (AMPLE ) initiated until the airwayno procedures areirway,A securedis Breathing Circulation Disability (Neurologic Dysfunction) Exposure / Environment Fracture
  23. 23. Lack of an airway is one of the few situations in medicine in which seconds count. Regarding the airway = assess, maintain, protect and provide * assess : a- disturbed conscious level . b- maxillo-facial orcervical trauma. c- vomiting. d- nasal or oral bleeding.
  24. 24. * maintain:
  25. 25. * maintain:
  26. 26. * protect: clearthe airwayif it becomes obstructed
  27. 27. * provide:
  28. 28. Indications of endotracheal entubation (ETE) in patients with major trauma: 1.Apnea (as part of CPR). 2.Respiratory insufficiency: • PO2 < 60 mmHg • PCO2 > 45 mmHg Normal PO2(adequate oxygenation)= 80-100 mmHg Normal PCO2 (adequate ventilation)= 35-45 mmHg 3.Risk of aspiration (disturbed consciousness with repeated vomiting). 4.Impending upper airway compromise (inhalation, maxillo- facial injuries). 5.Closed head injuries. (hyperventilation). 6. Flail chest: ????? Intubation and mechanical ventilation is rarely indicated for chest wall injury alone. Where ventilation is necessary it is pulmonary contusionsusually for hypoxia due to underlying
  29. 29. Types : -needle cricothyroidotomy -surgicalcricothyroidotomy
  30. 30. ? Cricothyroidotomy: more simple and faster than tracheostomy. not suitable for children < 10 years. needle cricothyroidotomy isn’t suitable for proper ventilation (temporary). surgical cricothyroidotomy can be used for ventilation for only 30-45 minutes.
  31. 31. ? Cervical spine should be considered unstable until proved otherwise by radiology (at least 3 views) esp. in: *Altered level of consciousness. *Blunt injury above the clavicle. *Cervical bonyabnormalities or tendernes. *Maxillofacial trauma. Stabilization of cervical spine: -Backboard and rigid neck collar. -Sand bags and fore head tape. -If a collar is not available, manual in line immobilization is necessary.
  32. 32. Having a patent airway is not necessarily associated with normal respiration. Abnormalrespiration after trauma may be : a. Central: e.g. severeheadtrauma→ respiratory centredepression. b. Peripheral (chest trauma):
  33. 33. Assessmentof breathing : 1- Inspection :- chest wall bulge or retraction. chest expansion. chest wounds. respiratory rate . tracheal shift. 2- Palpation :- surgical emphysema. tenderness. fracture click. flail segments. 3- Auscultation :- air entry at different lung fields on both sides. 4- Percussion :- (less commonly used ) for hyperresonance or dullness.
  34. 34. 5- Pulse oximetry ( ?unreliable) 6- ABG sampling 7- Chest Xray While reading a chest X ray film, a good trauma surgeon should be a good observer …. !!
  35. 35. Normal film Rt sided pneumothorax
  36. 36. Massive haemothorax pneumothorax
  37. 37. Flail chest Hypoxia 1- Rib fracture pain may cause the patient to hold the chest still. 2- Pulmonary contusion (if present) causes extravasation of fluid and blood into the alveoli. 3- Paradoxical respiration .
  38. 38. Pathophysiology
  39. 39. In the inspiratory phase, chest wall collapses inwards forcing air out of the bronchus of the involved lung into the trachea and bronchus of the uninvolved lung → mediastinal shift to the unaffected side
  40. 40. In the expiratory phase, chest wall balloons outwards so that air expelled from bronchus of the uninvolved lung into enters the trachea and bronchus of the involved lung → mediastinal shift to the affected side
  41. 41. This is a very insufficient form of respiration, and the patient will die of hypoxia and exhaustion if the condition is not relieved.
  42. 42. Tension pneumothorax is MAINLY a clinical diagnosis. Do not wait for radiographs if suspecting classic manifestations: -chest pain. -respiratory distress. -cyanosis. -refractory shock . -decreased breath sounds. -tympany of the affected lung. -jugular venous distension. -tracheal deviation to the opposite side
  43. 43. Tension (Massive) hemothorax is defined as 1500 mL of blood in the chest cavity . Patient who continues to bleed (a flow of 200 mL / h for 2-4 hours) may require thoracotomy to control bleeding.
  44. 44. Failure of peripheral circulation (i.e shock) is a very common cause of trauma-related death causes of post-traumatic shock: 1 - hypovolaemic (haemorrhagic) : the commonest= a shockedtraumatized patient is considered to have a hypovolaemic shock until proved otherwise. a traumatized patient with hypovolaemic shock is considered to have a haemorrhagic shock until provedotherwise. 2- neurogenic: severepain . 3- cardiogenic : haemopericarcardium or cardiac trauma 4- septic : late and rare .
  45. 45. * assess: A. symptoms: • thirst sensation. • air hunger. • coldness. • Restlessness (in early post-haemorrhagic state) then weakness & fainting. B. Signs: • With penetrating injuries obvious blood loss. • With multisystem blunt trauma multiple sources of potential haemorrhage are there. • Vital signs: - rapid weak "thready" or absent peripheral pulse. - low systolic BP (↓ blood volume→ ↓ VR→ ↓ COP & ↓ ABP) - RR: deep rapid= air hunger due to: * hypoxia (stimulationg RC). * acidosis. (why ??) *↓ vagal inhibition on medullary centres * catecholamines action on CNS. - Temp: subnormal (↓ metabolism)
  46. 46. Systemic signs of shock: • oliguria: (< 0.5-1 ml/kg/hour) due to: - ↓ Renal Blood Flow - ↑ ADH release. • skin ( of extremities): pale (skin capillary VC). cold (skin arteriolar VC). clammy (sweat secretion). cyanosis is LATE & indicates stagnant capillary circulation. • Peripheral veins (esp neck): collapsed low CVP.
  47. 47. * estimate: The amount of blood loss can be estimated as follows: - clinically (table of the next slide). - external blood loss : (WTa –WTb x 1.5 -2) - internal blood loss : ¤ type of injury : haematoma in closed fracture tibia → 500 – 1500 ml. haematoma in closed fracture femur →500 –2000 ml. haematoma in closed fracture pelvis →2000 –3000 ml. ¤ abdominal US or CT scan .
  48. 48. Class I Class II Class III Class IV Blood loss Up to 15% 15 – 30% 30 – 40% > 40% Mental state Normal to Anxious Anx. to Restless Aggressive or Drowsy Drowsy to unconscious Pulse / min < 100 100 - 120 100 – 140 140 Systolic BP Normal Normal (supine) ↓ ↓ Diastolic BP Normal ↑ ↓ ↓ Pulse P. Normal ↓ ↓ ↓ Cap. refill Normal > 2 sec > 2 sec > 2 sec R.R. 14 - 20 20 - 30 30 - 35 >35 Skin Normal Pale & cold Pale &colder P &very cold Urine (ml/h) 0 - 10 10 - 20 20 - 30 > 30
  49. 49. * treat: 1- treatment of the cause (e.g. control haemorrhage) 2- replacement of losses. 3- monitoring.
  50. 50. * treat: 1- treatment of the cause (e.g. control haemorrhage): • Cannon and colleagues (1923) first observed that attempts to↑ BP in soldiers with uncontrolled sources of haemorrhage is "counterproductive" with higher mortality due to: - More bleeding from the uncontrolled site. - Cooling effect of the fluid therapy. - Dilution of available coagulation factors by fluid therapy. • For actively bleeding patients, any delay in interference to control haemorrhage increases mortality, a goal of systolic BP of 80 to 90 mmHg may be adequate with profound haemodilution avoided by early transfusion of PRBCs. • They cannot be resuscitated until control of ongoing haemorrhage by: 1- Stopping external haemorrhage (Position, Pressure, Packing). 2- Stopping internal "intracavitary" haemorrhage.
  51. 51. * treat: 1- treatment of the cause (e.g. control haemorrhage). 2- replacement of losses: restore Circulating blood volume (fluid resuscitation): 1- Insert 2 wide-bore I.V. lines.: • short, wide-bore catheters allow rapid infusion of fluids. • Long, narrow lines (e.g. central venous catheters) have too high a resistance to allow rapid infusion and are more appropriate for monitoring than fluid replacement therapy. 2- Insert Foley's urinary catheter. 3- In patients with severe haemorrhage, intravascular volume restoration should be achieved with blood or blood products (oxygen carrying capacity of crystalloids and colloids is ZERO → if blood is lost, the ideal replacement fluid is blood). Fresh frozen plasma (FFP) should also be transfused in patients with massive bleeding orbleeding with ↑ PT or activated partial thromboplastin times 1.5 times greater than control. 4- Correct metabolic acidosis: • I.V. fluids to↑ tissue perfusion. • If resistant (pH ˂ 7)= give NaHCO3 0.5-1 meq/kg over 5-10 min and evaluate arterial pH to assess the need for incresing the dose.
  52. 52. * treat: 1- treatment of the cause 2- replacement of losses: 5- I.V. fluid administration: IV fluids come in four different forms: • Colloids • Crystalloids • Blood and blood products • Oxygen-carrying solutions COLLOIDS CRYSTALLOIDS These are fluids containing solutes in the form of large proteins or other similarly sized molecules that are so large that they cannot pass through the walls of the capillaries or into the cells. These are fluids containing electrolytes (e.g., Na, K, Ca, Cl) but lack large proteins and molecules found in colloids. They can significantly ↑ the intravascular volume because they: - remain for long periods of time in the BVs (large particles). - have the ability to absorb water from intracellular to intravsacular compartment "can ↓ oedema". They diffuse rapidly from circulation. Types of colloids: -Synthetic:Dextran, Hetastarch -Non-synthetic: Human serum albumin Plasma Dextran: is a polysacch. solution used for volume expansion associated with anticoagulation (e.g. for vascular surgery) as it interferes with coagulation & blood typing. Types of crystalloids: - isotonic fluids - hypotonic fluids - hypertonic fluids
  53. 53. Tonicity Osmosis Examples ISOTONIC As plasma No or minimal - normal saline (0.9% NaCl) - dextrose5% - ringers lactate: (Na, K, Cl & lactate) HYPOTONIC < plasma - Dilute serum → ↓osmolarity→ water moves from IV to IS compartment. - Poor volume expanders = not used in ttt of shock unless the deficit is free water loss (DI) or patient is sodium overloaded (LC). - half normal saline - dextrose2.5% HYPERTONIC > plasma - derive fluid from IS to IV - Useful for: * stabilizing BP * ↑ UOP * ↓ oedema. * correcting hypotonic ↓Na - May be hazardous in case of cellular dehydration. - 5% dextrose in 0.9% NaCl (D5NS) - 3% NaCl - 10% dextrose in water (D10W)
  54. 54. • The ideal fluid to be used continues to be debated; however, crystalloids continue to be the mainstay of fluid choice. • Hypertonic saline as a resuscitative fluid has also immunomodulatory action; resulting in decreased reperfusion-mediated injury with decreased O2 radical formation. • In patients with preexisting cardiac dysfunction, continuous monitoring of haemodynamic (by measurement of CVP or by use of pulmonary artery catheters).
  55. 55. Dynamic Fluid Response • Shock status can be determined dynamically by the cardiovascular response (HR, BP and CVP) to rapid administration of a fluid bolus. • Patients can be divided into 3 categories: i. Responders: sustained improvement in cardiovascular status= not actively losing fluid but require filling to a normal volume status. ii. Transient responders improve but then revert to their previous state over the next 10–20 min= moderate ongoing fluid losses. iii. Non-responders: severely volume depleted= likely to have major ongoing fluid loss, usually through persistent uncontrolled haemorrhage. • Adults not responding to 2 - 4 L of balanced electrolyte solution as lactated Ringer's(children are given 20 mL/kg) usually require blood transfusions. • Failure of response to fluid treatment may be due to: 1. Inadequate volume replacement. 2. Undetected blood loss (e.g. intracavitary). 3. Acute myocardial insufficiency (from direct injury or prolonged coronary hypoperfusion)
  56. 56. 3- Monitoring: The minimum standard for monitoring of a patient in shock is: • Continuous HR & O2 sat. monitoring (ECG & Pulse oximetry). • Frequent non-invasive BP monitoring. • Hourly UOP measurement. • Systemic and organ perfusion Most patients will need more aggressive invasive monitoring including CVP and invasive blood pressure monitoring. Systemic and organ perfusion • The goal of treatment is to restore cellular and organ perfusion, therefore, monitoring of organ perfusion should guide the management of shock (see table). • The best measure remains hourly UOP; however, this doesn't give a minute-to-minute view of the shock state. • Level of consciousness is an important marker of cerebral perfusion, but brain perfusion is maintained until the very late stages of shock and, hence, is a poor marker of adequacy of resuscitation. • Base deficit and lactate:
  57. 57. Base deficit and lactate: • It is measured by serum lactate level and/or base deficit from ABG analyses. • Patients with a base deficit of over 6 mmol/l have much higher morbidity and mortality rates than those with no metabolic acidosis. Endpoints of resuscitation • It is much easier to know when to start resuscitation than when to stop. • Traditionally amount of fluid given should be guided by: • Clinical improvement. • UOP. • CVP. • However, these parameters are monitoring organs whose blood flow is preserved till late stages of shock while gut and muscle beds may continue to be underperfused. Thus, activation of inflammation and coagulation. • This state of normal vital signs and continued underperfusion is termed occult hypoperfusion (OH). • Patients with OH for more than 12 hours have 2 - 3 times higher mortality rate than that of patients with a limited duration of shock. •Resuscitation algorithms are now directed at correcting global perfusion endpoints (base deficit, lactate, mixed venous oxygen saturation) rather than traditional endpoints. More research is under way to identify the pathophysiology behind this and investigate new therapeutic options.
  58. 58. * causes : head injury, shock , hypoxia and intoxication. * assess : AVPU method Alert and responsive . Vocal stimulus elicits response. Painful stimulus is needed to elicit a response . Unresponsive .
  59. 59. Response SCORE Eye opening response Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response Oriented 5 Confused 4 Inappropriate speech 3 Incomprehensible speech 2 None 1 Best motor response Obeys commands 6 Localizes pain 5 Withdraws to pain 4 Flexes to pain 3 Extends to pain 2 None 1
  60. 60. All clothes are removed using large sharp scissors. Antihypothermic measures: • Hypothermia in patient with bleeding leads to: 1- More bleeding 2ry to coagulopathy (due to impaired platelet function & coagulation cascade). 2- Hypotension. 3- Acidosis. • Provide comfortable warm environment (avoid excessive heat → excessive sweating→ more fluid loss). • Induction of controlled hypothermia in patients with severe shock may limit the metabolic activity and energy requirements (under trial).
  61. 61. Some cases may require transfer to another hospital with higher facilities or to another department in the same hospital. The level of care MUST not be allowed to DROP during the transfer .
  62. 62. Summary of the primary survey Airway - Airway opened, airway obstruction treated, possible definitive airway placed Breathing - Breathing assessed, treat threats. Circulation - Blood circulation and tissue perfusion assessed, intravascular volume loss replaced with fluids and blood, external hemorrhage controlled. Disability - Neurologic status assessed Exposure/environment - Patient fully undressed and environment controlled to protect from hypo or hyperthermia Consider transfer - For higher level of care if necessary. Adjuncts - Trauma radiographs, laboratory studies, urinary or gastric catheters, temperature monitoring, consider blood transfusion
  63. 63. Secondary Survey -starts once resuscitation efforts are underwent and preliminary X rays have been evaluated. -steps : * examine the patient from head to toe and from front to back. * complete and integrate all data (clinical, laboratory and radiological) . * Formulate a management plan .
  64. 64. Definitive Care * after identification of the cause & region of injury (after 2ry survey). * Patients with multiple injuries require the attention of a number of specialists. * The most appropriate person to take the primary responsibility in such cases is usually the general surgeon. * Patients require repeated evaluation as some injuries may present late e.g. delayed splenic injuries, retroperitoneal duodenal injuries and subdural hematomas.
  65. 65. hosam_hamza@ymail.com

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