Polytrauma and multiple traumata are medical terms describing the condition of a person who has been subjected to multiple traumatic injuries. This will be more prevalent in our country

1. Polytrauma

2. B Y : -
MAHESH S
MEDICAL SURGICAL NURSING
KGNC
polytrauma

3. Objective
• Definition
• Epidemiology Etiology
• Pathophysiology
• Type of shock in polytrauma
• Management of trauma

4. definition
Polytrauma is a significant injury in at least two of the
following six body regions:
Head , neck and cervical spine
Face
Chest and thoracic spine
Abdomen and lumbar spine
Limbs and bony pelvis
External (skin) Significant
injury in AIS>=3

5. Polytrauma expanded to include concurrent injury to two or
more body parts or systems that result in cognitive ,physical
,psychological or other psychosocial impairment.
Ex : TBI in combination with other disabiling condition like
amputation,auditory or visual impairment, PTSD and other
mental condition
definition

6. Abbreviated injury score AIS
>=3 injury severity score ISS
>=16

7. 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 injury
•One major system injury + one open grade 3 skeletal
injury
•Unstable pelvis # with associated visceral injury

8. The Golden Hour
• originated by R Adams Cowley
• first sixty minutes after the occurrence of
multi- system trauma
• victim's chances of survival are greatest
if they receive definitive care in the OR
within the first hour after a severe injury

9. Etiology of polytrauma
RTA
Fall from height (blunt or penetrating
injury)
Airplane crashes ,train derailment
Assault
Blast
Thermal ,chemical injury

10.  Polytrauma is the third most common
cause of death in all age group.
1-first peak-major neurological or vascular injury
2-second peak-intracranial hematoma , major
thoracic or abdominal injury
3-third peak-sepsis and multiple organ fail

11. Pathophysiology Of Polytrauma
Is complex phenomenon aiming at the restoration
of homeostasis and preservation of life

12. SIRS

13. Type of shock in polytraumatized
patient
1.Hemorrhagic shock
duo to loss blood voulme ,diagnosis based on vital sign and
examination characterized by hypotention tachycardia
and cold skin
2.neurogenic shock
duo to spinal cord injury that causes distribution of
sympathetic outflow to heart and blood vessles
characterized by hpotention .bradycardia .warm skin
3.hypoxic shock
4.septic shock

14. PHASES OF TRAUMA
CARE

15. CONCEPTS OF INITIAL
ASSESSMENT
1. Preparation
2. Triage
3. Primary survey
4. Resuscitation
5. Adjuncts to primary survey and resuscitation
6. Secondary survey
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring
and re-evaluation
9. Definitive care

16. Preparation
• Prehospital phase
➣coordination of EMS with hospital physicians
before the patient transport from the scene
• Time of injury
• Mechanism of injury
• Patient history
➣ airway maintenance
➣ control external bleeding and shock
➣ immobilization
➣ immediate transport to closest, appropriate facility

18. Step 1
Measure of vital signs and level of
consciousness
• GCS
• RR
• Systolic BP
• RTS
< 14
< 10 or > 29
< 90
< 11
YES - Take to Trauma center
NO - Assess Anatomy of Injury
Triage decision scheme

20. Triage decision scheme
Step2 Assess Anatomy of Injury
• Pelvic fracture
• Flail chest
• Two or more proximal long-bone fractures
• Combination trauma with burns of 10% or inhalation
injuries
• All penetrating injuries to head, neck, torso, and
extremities proximal to elbow and knee
YES - Take to Trauma center
NO – Evaluate for evidence of mechanism of injury and high-
energy impact

21. Triage decision scheme
Step3. Evaluation for evidence of mechanism of
injury and high-energy impact
• Ejection from automobile
• Death in same passenger compartment
• Pedestrian thrown or run over
• High speed autocrash
– Initial speed > 40 mph
– Velocity change > 20 mph
• Major auto deformity > 20 inches
YES - Take to Trauma centre
NO – Take to primary care centres

22. How to start triage

23. Inhospital phase
• Planning arrival
• Trauma room with equipment:
– For resuscitation
– Monitoring
– Warmed solutions
• Trauma staff
• Laboratory and radiology personnel
• Personnel protection from communicable
diseases (hepatitis & AIDS)

24. Minimum precautions
• Face mask
• Eye protection - goggles
• Water impervious apron
• Leggings
• Gloves
• Head covering
• Needles, blades, body fluids and tissues –
strictly enforced

25. ATLS
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.

26. ATLS- PRIMARY SURVEY
A – Airway maintenance & control of C.Spine.
B –Breathing & ventilation.
C– Circulation & haemorrhage control
D – Disability limitation
E –Exposure & environment.
F – Fracture stabilization, folly catheter.

27. ATLS- PRIMARY SURVEY
A – Airway maintenance & Control of
C.Spine
If conscious- Ask the pt’s name
If unconscious-Look for added
sounds (stridor,cyanosis etc)
If the pt does not respond to any
questions- resuscitate.
Always assume a cervical spine
injury is present

28. ATLS- PRIMARY SURVEY
A-AIRWAY
Sequence of events:
CHIN LIFT Jaw thrust
OPA
LMA
ENDO
-
TRACHEAL
TUBE
CRICO-
THYROIDOTO
MY
TRACHE-
OSTOMY

30. Primary Survey
B- Breathing & ventilation
• Exposure
• Inspection
• Auscultation
• Palpation
• Pulse oximetry
The aim is to hunt out & treat the life
threatening thoracic condns which include:

31. Primary Survey
B- Breathing & ventilation
life threatening
thoracic conditions:
1. Tension Pneumothorax
2. Open pneumothorax
3. Flail segment
4. Cardiac tamponade

32. Primary Survey
B- Breathing & ventilation
Respiratory distress
 Tracheal deviation
Diminished breath sounds
 Distended neck veins
Tension pneumothorax
Immediate needle thoracocentesis thro’
2ndintercostal space in mid clavicular
line reqd.

33. Primary Survey
B- Breathing & ventilation
Open pneumothorax:
Sealing of the wound
Tube thoracostomy
Flail segment:
Endotracheal intubation
Mechanical ventilation

34. Primary Survey
B- Breathing & ventilation
Cardiac tamponade
(almost always seen with a penetrating wound)
Beck’s triad:
Treatment: needle pericardiocentes
Thoracotomy

35. ATLS- Primary Survey
C- Circulation and hemorrhage control
Assessment of blood loss
External or obvious
Internal
Resuscitation
Arrest bleeding
Obtain vascular access

36. • Verify pulses, bilateral blood
pressures
– Radial pulse = SBP 90
mmHg
– Femoral pulse = SBP 70-
80 mmHg
– Carotid pulse = SBP 60
mmHg
• Largest blood loss in thorax,
abdomen, pelvis, extremities

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

38. • General : sign & symptoms of inadequate
perfusion
• Urinary Output : 0.5 ml/kg/hour in adult
• Acid/Base Balance : respiratory alkalosis
follow by metabolic acidosis
ATLS- Primary Survey
C- Circulation and hemorrhage control

39. ATLS- Primary Survey
C- Circulation and hemorrhage control
Immediate responders-<20% blood loss
Bleeding ceases
spontaneously
Transient responders-
bleeding within body
cavities
Surgical intervention reqd.
Non responders- <40%of blood vol lost require
immediate surgery, Continued IV fluids

40. ATLS- Primary Survey
C- Circulation and hemorrhage control
Estimation of blood loss

41. ATLS- Primary Survey D-
Disability limitation
C.N.S.
Rapid assessment
of motor & sensory
functions
AVPU
A.-Alert
V.-Responds to
Voice
P.-Responds to
Pain
U.-Unresponsive
Pupil.-Size and
reaction

42. ATLS- Primary Survey D- Disability
limitation
• Remove remaining clothing
• Prevent hypothermia

43. CRITICAL DECISIONS
Decision making
Responding well
Secondary
assessment
Transient responders
Critical care unit
Failure to respond
Critical care unit

44. ATLS- Primary Survey
E-EXPOSURE
• Undresses for assessment
• After assessment is completed, it is
imperative to cover patient with warm
blankets or external warming devices to
prevent ‘Hypothermia’
• IV should be warmed before infusion and
warm environment

45. ADJUNCTS TO
PRIMARY
SURVEY
AND RESUSCITATION

46. FAST

47. Focused Assessment with
Sonography for Trauma (FAST)
 Detect intra-abdominal fluid
 Rapid, noninvasive, accurate, inexpensive, can
repeat frequently
 Factors that compromise its utility are obesity,
presence of subcutaneous air, previous
abdominal operation

48. FAST

49. Secondary Survey
• Does not begin until the primary survey
(ABCDEs) is completed
• Head-to-toe evaluation (complete history,
physical examination, reassessment of all
vital signs)

50. History
• A Allergy
• M Medication currently being taken
by the patient
• P Past illness and operation
• L Last meal
• E Event and Environment related to
the injury

51. Secondary Survey
Rapid Head-to-Toe Examination
• HEAD: scalp, pupils, ears, face, mouth
• Neck: distended neck veins, trachea
midline, posterior midline deformity
• Chest wall: paradoxical movement, 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: feels all four/moves all
four

52. Adjuncts to the Secondary survey
Further investigation for specific injuries
that non-life threatening condition e.g.
- x-ray spine and extremities
- CT scan
- contrast angiography
- Transesophageal ultrasound
- Bronchoscopy

53. TRAUMA TEAM MEMBERS

54. Patient
Airway: RT/EMT
Ventilation,assist withintubation,
keep patient informed
Vitals & Recorder: LPN/EMT
Takes serial vitals and records on Trauma Form
Other duties as needed
IV /Procedures: RN
Insert large bore IV,remove clothing from left
side of body, Intake/Output neuro assessment,
Scribe: EMT/LPN
Record case on white board
Provider Assist: RN
Assist with procedures as directed
Provider
Runner: EMT/CNA/Secretary
Retrieve equipment/supplies, assist with
ER traffic control, answer phone
TRAUMA TEAM ROLES - Guidelines
IV/Meds: RN
Insert large bore IV,remove clothing
from right side of body,
attach/observe monitor, access crashcart
Prepare/Administer Meds
Foley as appropriate
C-Spine: EMT
Alert physician of any
change in LOC