published 1 march 2019

1. Polytrauma
Moderator-Associate prof.Dr.Mehedy Newaz.
MBBS,MS(Ortho)
Dr.Md.Shaukat Shorif
Resident,D-ortho course,
Khulna Medical College,Khulna.

2. Polytrauma
Defined as
“a clinical state following injury to
the body leading to profound physiometabolic
changes involving multisystems that may give rise
to a life treatening situation.”

3. Polytrauma
Patient with anyone of the following combination of
injuries
TWO MAJOR SYSTEMS INJURY + ONE MAJOR LIMB INJURY.
ONE MAJOR SYSTEM INJURY + TWO MAJOR LIMBS INJURY.
ONE MAJOR SYSTEM INJURY + ONE OPEN(G-III) SKELETAL INJURY.
UNSTABLE PELVIS FRACTURE WITH ASSOCIATED VISCERAL INJURY.

6. Epidemiology
World wide No.1 killer amongst the younger age
group (18-44 yrs).
 3rd most common cause of death in all age group.
Great economic & social loss to country.
Less than 2% of budgets for health services spend
on trauma patients.
TRAUMA- Neglected Disease of
Modern Society

8. POLYTRAUMA / MULTIPLE FRACTURES
 Polytrauma is not synonym of multiple fractures.
 Multiple fractures
are purely orthopaedic problem as there is
involvement of skeletal system alone. While in
 Polytrauma
there is involvement of more than one
system,like associated head/spinal injury, chest injury,
abdominal or pelvic injury.

9. IS THIS A POLYTRAUMA???

11. Systemic Inflammatory Response
Trauma→cytokines↑→ activate immune system
as well as complement system
A compensatory anti-inflammatory
response→post-traumatic immunosupression

12. Inflammatory Markers
Interleukin(IL)-1, IL-6, IL-8, IL-10, CRP, TNF-‫ﻪ‬
Measure and monitor inflammatory response to
major trauma
IL-6 is recommended
Help orthopaedic surgeon to determine appropriate
timing of fracture fixation in severely injuried
patients

13. Systemic Inflammatory Response
• This metabolic changes are found in the
hyperdynamic phage traumatic response of the body.
• These substances are mainly released from
endothelial and reticuloendothelial cells mainly
macrophage.

14. Systemic Inflammatory Response
Exaggerated inflammatory response
→ Neutrophil demargination, vascular endothelium
disruption .
This endothelial damage leads to increased
microvascular permeability with the formation of
protein rich edema fluid.
 Microcirculation disturbance, tissue hypoxia leads
to parenchymal necrosis.
 SIRS, ARDS, multiple organ failure

15. “Two Hit “ hypothesis
Initial trauma, surgical intervention: 2 hits
Surgery performed in posttraumatic period may
increase inflammation response ( marker) and cause
multiple organ failure or ARDS.
38% of secondary surgery in multiple injuried
patients preceded a deterioration in organ function

16. Physiometabolic changes in Polytrauma
A)Metabolic changes
B)Circulatory changes

17. A)Metabolic changes
a)Early or ebb phase(24 to 48 hours):
characterized by-
 1)Decreased metabolic rate
 2)Increased release of cathecolamines
Incresed glycogenolysis in liver
Promotes gluconeogenesis in liver
Lactic acid is released from muscle & converted to glucose
in liver(Diabetes of trauma)
Lipolytic effect:fatty acid is released from adipose
tissuemetabolic acidosis

18. Metabolic changes cont…
b)Convelescence or High flow phase:
a)Catabolic phase:characterized by-
 Negative nitrogen balance
 Sodium & water retension
 Potassium depletion
b)Anabolic phase:
Positive nitrogen balance
Na+ & water depletion
K+ retension

19. Circulatory changes
3 Phases:
Phase 1:
Immediate syncope
Redistribution of available blood to vital centers
Phase 2:Restoration of blood volume
Phase 3:Replacement of red cells

20. TRIMODAL DISTRIBUTION OF
DEATH
 Immediate
death(50%)
Occurs within minutes
 Early death (30%):
Occurs with in 1 to 3 hrs
 Late death( 20%):
Occurs with in 1 to 6 wks
Golden
Hour

21. 1st Peak of death
With in minutes
Severe head injury
Brain stem injury
High cord injury
Heart & major vessels injury

22. 2nd peak of death
Intra cranial bleeding
Chest injury
Abdominal bleeding
Pelvic bleeding
Multiple limb injury

23. 3rd peak of death
Several Days or Weeks
Sepsis
Multy organ failure
Influence by Early managemament

24. Trauma Care Staging
Pre-hospital care:
Organization
Safety on scene-including personal protection
Immediate action & Triage
Assessment & initial management(BLS protocol)
Transfer to hospital
Helicopters & air ambulance

25. Trauma Care Staging
Hospital care:
Organization:
a)Receiving hospital
b)Trauma units
c)Major trauma Centres
Trauma teams
Assessment & management-The ATLS concept
Definitive & systemic management.

26. Golden Hour
The Golden Hour is a theory stating that the
best chance of survival occurs when a seriously
injured patient has emergency management
within ONE hour of the injury.
Platinum 10 minutes:
Only 10 minutes of the Golden Hour may be
used for on-scene activities

27. Dr.Donald Trunky have summerized the
“GOLDEN HOUR” by 3R rules-
Right Patient to
Right Place at
Right Time

28. Triage
It means-to sort
Triage is the process
of prioritizing patient
treatment during the
mass casualty events.

29. Stages of Triage
2 Stages of Triage
Triage sieve:
Quick and uncomplicated system based on simple
clinical observation,ability to walk, breathe and
maintain peripheral perfusion.
Performed by trained, but non-clinical personnel.
Triage sort:
It requires a degree of clinical training and uses
physiological measurements to score casualties and
place them into priority groups.

30. Priority categories of Triage
Category 1: Immediate & Critical Red
Category 2: Urgent,can wait 30 minutes at
most
Yellow
Category 3: Delayed.Less serious injury Green
Category 4 Dead.Survival not likely White
Both triage systems place casualties into 4
colour-coded priority categories:

31. The Revised Trauma Score
Used in the out-of hospital setting as a tool for
trauma center triage.
 Also used as a prognostic tool for survival.
RTS utilizes 3 physiologic parameters:
Glasgow Coma Scale (GCS)
Systolic blood pressure (SBP)
Respiratory rate (RR)

32. The Revised Trauma Score
Glasgow
Coma Scale
(GCS)
Systolic Blood
Pressure
(SBP)
Respiratory
Rate
(RR)
RTS
Value
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0

33. Trauma Team
Emergency Department physician
Anaesthetist and anaesthetic technician
 Emergency Department nurses
Radiographer
General surgeon and orthopaedics surgeon
Intensive care specialists
Appropriate specialists according to needs.

34. Management

35. Aims in Management
“TO RESTORE THE PATIENT BACK TO HIS
PREINJURY STATUS”
HAVING FOLLOWING PRIORTIES:
Life salvage
Limb salvage
Salvage of the total functions if possible

36. Principles of management
ADVANCED TRAUMA LIFE SUPPORT - based on
‘TREAT LETHAL INJURY FIRST, THEN
REASSESS AND TREAT AGAIN’
The steps in management are:
Primary survey with simultaneous
resuscitation:Identify & treat what is killing the patient.
Secondary survey:proceed to identify all other
injuries
Definitive care.

37. Primary Survey
Airway maintenance with cervical spine control.
Breathing and ventilation
Circulation –control of haemorrhage.
Disability:Neurological status
Exposure:Proper expose the patient and asses for
other injuries(exposure with environment control).

38. PRIMARY SURVERY
During the primary survey life threatening
conditions are identified and manage it
simultaneously.
Airway obstruction
Tension pneumothorax
Hemothorax
Open thoracic injury and Flail chest
Cardiac temponade
Massive internal or External
hemorrhage

39. ADJUNCTS TO PRIMARY SURVEY
Vital signs:Pulse,BP,Temp
ECG
End-tidal CO2 monitoring
Urinary output:Child:0.5 ml/kg/hr Adult:1 ml/kg/hr
Blood for CBC,RBS,Blood
urea,S.creatinine,S.electrolytes
Nasogastric tube (unless contraindicated)
Chest X-ray
Pelvic X-ray

40. Airway maintenance & cervical spine
protection`
Assessment of-
Patency of airway
Any airway obstruction
Check for trachea,larynx & fasciomaxillary injury

41. Management:
Patency of airway established by `Chin lift` or Jaw
thrust maneuver
Clean the airway(FB,Vomitus,secreation)by suction
Endotracheal intubation or tracheostomy(if needed)
Stabilize the cervical spine with neck brace,sand bag
etc(in a neutral position).

42. Breathing & Ventilation
Assessment of the patient-
Cyanosis
Rate & depth of respiration
Any abnormality in the chest wall movement
Position of the trachea
Chest percussion & auscultation
Check for pneumothorax,Haemothorax,# rib etc

43. Breathing & Ventilation
• Management:
according to the cause,i.e-
If tension pneumothoraxNeedle
decompression followed by thoracotomy
Cardiac tamponadeNeedle or open
pericardiocencenthesis
Open sucking chest:Temporary sealing or open
sucking chest followed by occlusive dressing

44. Circulation & control of Haemorrhage
• Assessment-
Identify the site of bleeding
Blood pressure
Carotid pulse (absent or present)
Capillary refill
Skin color
Skin temperature

45. Management:
Control of external bleeding by direct pressure,pack etc
Open 2 I/V channels with short wide bore I/V
cannula(16 to 18 G)
Send blood for grouping & cross matching
Start I/V fluid:Hartmann solution/Ringer`s Lactate
solution or Normal saline(Never DA)
Urinary catherization
If central pulse is absent, begin CPR

46. DISABILITY(NEUROLOGICAL EVALUATION)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Assessment of pupillary size and reaction
Not forget to use also Glasgow Coma Scale.

47. Glasgow Coma Score
 If GCS < 10 CT
head is indicated
GCS < 8 indicate
ICU support
Eye Opening
Spontaneous 4
To voice 3
To pain 2
None 1
Verbal Response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Motor Response
Obeys command 6
Localizes pain 5
Withdrawn (pain) 4
Flexion (pain) 3
Extension (pain) 2
None 1

48. Exposure and environment
Completely undress the patient
Warm blanket to prevent hypothermia
Examine the patient from front & back using a
careful controlled log roll.

49. Don`t forget the back

50. Critical decision
Critical decision is made according to respond
of the patient
1)Respond to resuscitation:
Send the patient to ward for further resuscitation
2)Transient respond to resuscitation:
Send the patient to ICU
Non-responder:
Send the patient to OT for definative or damage
control surgery.

51. Medication
 Tetanus prophylaxis
 Steroids
 Inotrophic drugs
 Antiobiotics
 Calcium gluconate
 Bicarbonate

52. Damage control surgery
Rapid initial control of haemorrhage & contamination
& further damage with packing, temporary closure
or,followed by resuscitation in ICU and subsequent re-
exploration & definative repair & fixation once normal
physiology has been restored.

53. Principles
Control of haemorrhage
Identification of injury
Prevention of contamination
Avoid further injury

54. Stages of DCS
Stage 1:Minimum surgery is done
 achieve haemostasis.
 Limit the contamination
 Temporary closure or stabilisation)
Stage 2:
Resuscitation in ICU & correction of “Lethal triad”.
Stage 3:
Return to OT for definitive surgery.

56. Complication of DCS
Sepsis & multi organ failure
Pneumonia
Intra abdominal abscess
Enteric fistula
Compartment syndrome

57. Secondary Survey
Components:
Detail history taking(AMPLE)
A-Allergy
M-Medication
P-Past medical history
L-Last meal
E-Event of incidence
Head to toe examination
Imaging & laboratory studies
Seek for any associated injury

58. Definative care
A definitive treatment plane according to
cause.

59. Spinal injuries
• Any pt suspected of
spinal injury must be
immobilised unless spine
has been cleared
• Cervical collar
• Spine board
• Log roll technique
Log roll technique

60. PHILADELPHIA COLLAR
• 35

61. Pelvic injuries
Pelvic fracture acounts for <5% of all skeletal injury
associaated with soft tissue injury & blood loss.
Pelvic injuries are assesed during secondary survey
Pelvis x-ray is mandatory in polytrauma pt
Mortality rate range from about 10% to 50% due to
shock,sepsis or ARDS.
Uretheral injury transurtheral catheter or suprapubic
catheter

62. Immediate Mx of severe pelvic bleeding
Consideration of haemodynamic status
Follow routinely ATLS protocol
Stabilization by-
Pelvic binder
External fixation
C-clamp
Pneumotic anti-shock garment
Traction
Surgical treatment generally reserve for unstable
injury by ORIF with treatment for rupture &
bladder.

63. External fixation

65. Polytrauma in pregnant female
Tratement priorities are same as for non pregnant pt
Unless spinal injury is present pt should be
examined in left lateral position
Pt can loss upto 35%of blood before tachycardia and
hypotension appears
Fetus may be in shock while mother appears normal
1st resuscitate the female than monitor the fetus

66. MANAGEMENT OPEN PNEUMOTHORAX
Ensure adequate airway
100% oxygen
Seal open wound
IV access
Notify Medical Direction

67. SEALING THE OPEN WOUND
Asherman chest seal is very effective

68. SEALING THE OPEN WOUND
You can use impervious material taped on three sides

69. MANAGEMENT
TENSION PNEUMOTHORAX
Ensure adequate airway
100% oxygen
Needle decompression or water seal drainage
if indicated
IV access
Notify Medical Direction

70. Management of Flial chest
Patient is treated in ICU/HDU
Respiratory physiotheraphy
Serial arterial blood gas analysis
Pt needs IPPV for about 2 to 3 weeks upto flial
segment gets established.
Routine fixation of flial segment is not required

71. Management of Flial chest
Others general care:
 Intermittent suction
 Care of bowel & bladder
 Skin care
 Maintenance of nutrition
 Antibiotics
 Analgesic

72. REHABILITATION
Restoration to pre injury status
Starts with reception, ends with ambulation
Limb mobilization & postural change to prevent
subclinical DVT,pressure sores, disuse atrophy,
stiffness and contractures.
Helps to augment anabolic status

73. MESSAGE
Polytrauma Management
Its not only important to
Save A Life
But to ensure that
THE EFFORTS
Help the victim to end up with
Good Quality of Life
with no or minimal
Functional Disability.

74. Thank You All