Downloaded 1,687 times
Polytrauma Management
The document discusses polytrauma and its management, highlighting its significant impact on mortality and healthcare costs in both the UK and USA. It covers injury mechanisms, triage procedures, and the Advanced Trauma Life Support (ATLS) protocol, emphasizing the importance of swift intervention and management by a specialized trauma team. Additionally, it addresses complications arising from trauma, the need for a multi-specialty approach in treatment, and the necessity for improved funding and legislation to tackle high-velocity trauma effectively.
More Related Content
Similar to Polytrauma Management
![Approach_to_the_trauma_patient[1].pptx](https://cdn.slidesharecdn.com/ss_thumbnails/approachtothetraumapatient1-220906191256-c4d92395-thumbnail.jpg?width=640&height=640&fit=bounds)
More from Department of Health & Family Welfare, Government of West Bengal
Polytrauma Management
- 1. POLYTRAUMA & ITS MANAGEMENT DR. A.SENGUPTA , Assoc. Prof. Dr. S. SAHA, Prof. Department of Orthopedics R.G.Kar Medical College KOLKATA
- 3. INTRODUCTION UK - >18, 000 deaths annually. > 60, 000 hospital admission. > Costing 2.2 billion pounds. USA - > 120, 000 deaths annually. > 100 billion dollars.
- 4. MECHANISMS OF INJURY Typesof injuryTypes of injury โข Penetrating. โข Non-penetrating blunt. โข Blast. โข Thermal. โข Chemical. โข Others - crush & barotrauma.
- 5. TRIMODAL DISTRIBUTION OF DEATH Immediatedeath (50%) 0 to 1 hr Early death (30%) 1 to 3 hrs Late death ( 20%) 1 to 6 wks Golden Hour
- 6. ADVANCED TRAUMA LIFE SUPPORT( ATLS) PHILOSOPHY Treat lethal injuries first Reassess Treat again
- 7. ATLS โ COMPONENTSTEPS 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.
- 8. PREHOSPITAL RETRIEVAL & MANAGEMENT AIMS Accessof the patient Smooth transfer APPROACHES Scoop & Run policy Stay & Play policy
- 9. ORGANISATION OF TRAUMA CENTRES LEVEL1 โ REGIONAL TRAUMA CENTRES LEVEL 2 โ COMMUNITY TRAUMA CENTRES LEVEL 3 โ RURAL TRAUMA CENTRES
- 10. MANAGEMENT IN HOSPITAL The TRAUMACENTRE should be adequately equipped with ATLS Trained Personnel
- 11. MANAGEMENT IN HOSPITAL THETRAUMA TEAM comprises initially of 4 Doctors At least 1 Anaesthetist 1 Orthopaedician 1 General surgeon 5 Nurses 1 Radiographer
- 12. But no morethan 6 people should touch the patient at one time
- 13. CAPTAIN OF THETRAUMA TEAM Most experienced. Preferably a general surgeon. Takes all TRIAGE decisions. Should be familiar with each membersโ skills. Prioritise procedures. Communicate with consultants & family members.
- 15. TRIAGE TRIAGE SIEVE โto separate dead & the walking from the injured TRIAGE SORT โ to categorise the casualties according to local protocols. Cat 1 : critical & cannot wait. Cat 2 : urgent โ can wait for 30 mins at most Cat 3 : less serious injuries. Cat 4 : expectant โ survival not likely.
- 16. How to triage? 1. Canthe patient walk? Yes delayed No check for breathing 2. Is the patient breathing? No open the airway Are they breathing now? Yes IMMEDIATE No DEAD Yes count the rate <10 & > 30 / min โ IMMEDIATE 10 โ 30 /min โ check circulation 3. Check the circulation Capillary refill> 2 sec- IMMEDIATE Capillary refill < 2 secs - urgent
- 17. TRAUMA TEAM CALL-OUTCRITERION โข Penetrating injuries โข Two or more proximal bone fractures โข Flail chest & pulmonary contusion โข Evidence of high energy trauma - fall from > 6ft -changes in velocity of 32 kmph - 35 cm displacement of side wall of car - ejection of the patient - roll-over - death of another person in same car - blast injuries
- 19. ATLS Primary survey &resuscitation follows ABCDE sequence Only radiographs permitted during this phase are - cross table lateral C- spine X-ray - AP supine chest X-ray - AP plain pelvic film
- 20. ATLS- PRIMARY SURVEY Aโ Airway maintenance & control of C.Spine. B โ Breathing & ventilation. C โ Circulation & haemorrhage control D โ Disability limitation E โ Exposure & environment. F โ Fracture splintage.
- 21. ATLS- PRIMARY SURVEY Aโ Airway maintenance & Control of C.Spine If conscious- Ask the ptโs name If unconscious-Look for added sounds (stridor,cyanosis etc) If the pt does not respond to any questions- resuscitate.
- 22. ATLS- PRIMARY SURVEY A-AIRWAY Sequenceof events: chin lift Jaw thrust finger sweep suction Oropharyngeal/ orotrachial tube Cricothyroidotomy Trachiostomy
- 23. ATLS- Primary Survey B-Breathing & ventilation โข Exposure โข Inspection โข Palpation โข Movement โข Auscultation The aim is to hunt out & treat the life threatening thoracic condns which include:
- 24. ATLS- Primary Survey B-Breathing & ventilation Five life threatening thoracic conditions: 1. Tension Pneumothorax 2. Massive Pneumothorax 3. Open pneumothorax 4. Flail segment 5. Cardiac tamponade
- 25. ATLS- Primary Survey B-Breathing & ventilation Tension pneumothorax C/F Respiratory distress Tracheal deviation Diminished breath sounds Distended neck veins Immediate needle thoracocentesis throโ 2nd intercostal space in mid clavicular line reqd.
- 26. ATLS- Primary Survey B-Breathing & ventilation Suction pneumothorax: Sealing of the wound Tube thoracostomy Flail segment: Endotrachial intubation Mechanical ventilation
- 27. ATLS- Primary Survey B-Breathing & ventilation Cardiac tamponade (almost always seen with a penetrating wound) Beckโs triad: Hypotension distended neck veins Muffled heart sounds Pulsus paradoxus Treatment: needle pericardiocentes Thoracotomy & repair as def managemnt
- 28. ATLS- Primary Survey C-Circulation and hge control Tachycardia in a cold patient indicates shock Causes of shock following injury: 1. Hypovolemic 2. Cardiogenic 3. Neurogenic 4. Septic
- 29. ATLS- Primary Survey C-Circulation and hge control Assessment of blood loss External or obvious Internal or covert chest abdomen pelvis limbs Resuscitation Arrest bleeding Obtain vascular access
- 30. ATLS- Primary Survey C-Circulation and hge control Adults- 2 lit of Ringer lact soln as initial fluid challenge Children- 20mg/kg of body wt Response to initial fluid challenge: โข Immediate & sustained return of vital signs. โข Transient response with later deterioration โข No improvement.
- 32. ATLS- Primary Survey C-Circulation and hge 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 detrimental
- 33. ATLS- Primary Survey C-Circulation and hge control Urine output โ 0.5ml/kg/hr in adults 1ml/kg/hr in children 2ml/kg/hr in infants
- 34. ATLS- Primary Survey C-Circulation and hge control Estimation of blood loss
- 35. ATLS- Primary Survey D-Disability limitation C.N.S. โข Rapid assessment of motor & sensory functions โข AVPU pupillary assessment by prehospital personnel A.-Alert V.-Responds to Voice P.-Responds to Pain U.-Unresponsive Pupil.-Size and reaction
- 36. ATLS-Primary survey E- Exposureand environment โข Remove remaining clothing โข Prevent hypothermia
- 37. ATLS-Primary survey F- Fracturemanagement 1. Minor 2. Moderate open # of digits undisplaced long bone or pelvis # 3. Serious closed long bone #s multiple hand/foot #s 4. Severe life threatening open long bone # pelvis # with displacement dislocation of major joints multiple amputations of digits amputation of limbs multiple closed long bone #s
- 40. CRITICAL DECISIONS Decision making ๏Respondingwell ๏จ Secondary assessment ๏Transient responders ๏จ Critical care unit ๏Failure to respond ๏จ Shift to O.T. ๏จ Critical care unit
- 41. Medication โข Tetanus prophylaxis โขSteroids โข Inotrophic drugs โข Antiobiotics โข Calcium gluconate โข Bicarbonate
- 43. Secondary survey (ATLS) โขComprises of head to toe examn of the stable pt โข Requires Detailed history Thorough examination check the vital signs monitoring devices -pulse oximeter -rectal thermometer โข Detailed radiographic procedures -C.T., USG, M.R.I.
- 44. Secondary survey (ATLS) HEAD โขGlasgow coma scale โข Reaction and size of pupils โข Plantar response โข Signs of rhinorrhoea,otorrhoea
- 45. GLASGOW COMA SCALE Eyeopening โข Spontaneous 4 โข To voice 3 โข To pain 2 โข None 1 Verbal response โข Oriented 5 โข Confused 4 โข Inapp words 3 โข Incomp sounds 2 โข None 1 Motor response โข Obeys commands 6 โข Localises pain 5 โข Withdraws 4 โข Flexion(pain) 3 โข Extension (pain) 2 โข None 1 Total 3-15
- 46. Secondary survey (ATLS) NECK โขSubcut emphysema โข Cervical spine fractures (specially C1,C2,C7) โข Penetrating neck injuries
- 47.
- 48. Secondary survey (ATLS) THORAX Searchfor potentially life threatening injuries โข Pulmonary complication โข Myocardial contusion โข Aortic tear โข Diaphragmatic tear โข Oesophageal tear โข Tracheobronchial tear โข Early thoracotomy if initial haemorrhage > 1500 ml
- 49. Secondary survey (ATLS) ABDOMEN โขFingers and tubes in every orifice โข Nasogastric and Urinary catheter for diagnosis and treatment โข Rectal exam โข Wounds coverage โข Eviscerated bowels packed by warm wet mops
- 50. Secondary survey (ATLS) ABDOMEN Forrigid and distended abdomen โข Four quadrant tap โข Diagnostic peritoneal lavage โข Ultrasound โข Laparoscopic examination Consider rapid surgical exploration Any deterioration
- 51. Secondary survey (ATLS) PELVIS Clinicalassessment X-ray stabilize pelvis with fixator/clamps If urethral injury is suspectedโhigh up prostate in PR blood in meatus Trial catheter perineal haematoma With gentle manipulation ascending Fine catheter urethrogram Lots of lubricants In OT suprapubic cystotomy Ifnot
- 52.
- 53. Secondary survey (ATLS) Spinalinjury Thorough sensory and motor examination โข Prevent further damage in unstable fractures โข Log rolling for full neurological examination-5 people required โข Use a long spine board for transportation
- 55. Secondary survey (ATLS) EXTREMITIES โขFull assessment of limbs for assessment of injury โข Always look for distal pulse & neuro-status โข Carefully look for skin & soft tissue viability โข Look out for impending Compartment syndrome
- 56.
- 57.
- 59. Secondary survey (ATLS ) EXTREMITIES Mangled Extremity Severity Score ( MESS ) based upon โ 1. Skeletal / Soft tissue group 2. Shock group 3. Ischaemia group 4. Age group If > 7, limb salvage is questionable
- 62. Definitive care plan(ATLS) Multi-specialityapproach ( Inter-disciplinary management ) The most appropriate person in- charge is the General / Orthopaedic surgeon.
- 65. Current concepts Permissive hypotension Maintainsystolic B.P. at 85 - 95 mm of Hg Turn off the tap and do not infuse too much of fluid and blood products
- 66. Complications โข Tetanus โข A.R.D.S. โขFat embolism โข D.I.C. โข Crush syndrome โข Multisystem organ failure (M.S.O.F.)
- 67. Complications A.R.D.S.A.R.D.S. โข Tachypnoea โข Dyspnoea โขBilateral infiltrates in C XR Treated with mechanical ventilation CPAP with or without PEEP Glucocorticoids Inhaled nitric oxide
- 68. Complications Fat embolismFat embolism โขAround 72 hours โข Tachycardia โข Tachypnoea โข Dyspnoea โข Chest pain โข Petechial haemorrhage Treated with ----- mechanical ventilation ------anticoagulants ------fixation of fractures
- 69. Complications Disseminated intravascular coagulationDisseminatedintravascular coagulation โข Follows severe blood loss and sepsis โข Restlessness , confusion,neurological dysfunction,skin infercation,oligurea โข Excessive bleeding โข Prolonged PT,PTT,TT,hypofibrinogenemia Treatmentโ prevention and early correction and shock
- 70. Complications Crush syndromeCrush syndrome โขWhen a limb remains compressed for many hours โข Compartment syndrome and further ischaemia โข Cardiac arrest due to metabolic changes in blood โข Renal failure Treatment โข Prevention-ensure high urine flow during extrication โข IV Crystalloids,Forced mannitol alkaline diuresis โข Fasciotomy and excision of devitalised muscles โข Amputation
- 71. Complications M.S.O.F.M.S.O.F. Progressive and sequentialdysfunction of physiological systems Hypermetabolic state It is invariably preceded by a condition known as Systemic Inflammatory Response Syndrome (SIRS) Characterised by two or more of the following โข Temperature >38ยบ C or < 36ยบC โข Tachycardia >90 /min โข Respiratory rate >20/min โข WBC count >12,000/cmm or <4,000/cmm
- 72. Complications M.S.O.F. Treatment : Keyword is PREVENTION โข Prompt stabilisation of fracture โข Treatment of shock โข Prevention of hypoxia โข Excision of all dirty and dead tissue โข Early diagnosis and treatment of infection โข Nutritional support
- 73. Conclusion High velocity traumais aptly called neglected step child of modern civilisation being the number one cause of death in 18 to 34 years age group. Despite the major economic productivity losses due to this problem injury receives < 2 % of the total health budget allocation. Adequate funding & legislations must be passed to reduce the enormous impact on the society.