Describes polytrauma and it's management

1. POLYTRAUMA
Dr Vidya Sagar
Senior Resident
Dept of Orthopaedics

2. DEFINITION
There is no consensus definition, but the polytrauma patient can be
defined as follows:
• Injury severity score (ISS) >18
• Hemodynamic instability or coagulopathy present on admission
• More than one system involvement: central nervous system (CNS),
pulmonary, abdominal, musculoskeletal, etc.

3. FIELD TRIAGE
Management Priorities
• Assessment and establishment of airway and ventilation
• Assessment of circulation and perfusion
• Hemorrhage control
• Patient extrication
• Shock management
• Fracture stabilization
• Patient transport

4. GOLDEN HOUR
• Rapid transport of the severely injured patient to a trauma center is
essential for appropriate assessment and treatment.
• The patient’s chance of survival diminishes rapidly after 1 hour, with a
threefold increase in mortality for every 30 minutes of elapsed time
without care in the severely, multiply injured patient

5. THE TEAM
• The trauma team is headed by the trauma general surgeon, who acts
as the “captain of the ship” in prioritizing and directing patient care.
• The orthopaedic consult is available to assess all musculoskeletal
injuries, provide initial bony stabilization, and work in concert with
the trauma general surgeons to treat shock and hemorrhage.

6. RESUSCITATION
Follows ABCDE:
• Airway,
• Breathing,
• Circulation,
• Disability,
• Exposure

7. AIRWAY CONTROL
• The upper airway should be inspected to ensure patency.
• Foreign objects should be removed and secretions suctioned.
• A nasal, endotracheal, or nasotracheal airway should be established as
needed.
• A tracheostomy may be necessary.
• The patient should be managed as if a cervical spine injury were
present. However, no patient should die from lack of an airway because
of concern over a possible cervical spine injury. Gentle maneuvers, such
as axial traction, are usually possible to allow for safe intubation
without neurologic compromise.

8. BREATHING
This involves evaluation of ventilation (breathing) and oxygenation.
The most common reasons for ineffective ventilation after
establishment of an airway include
• Malposition of the endotracheal tube,
• Pneumothorax, and
• Hemothorax.

9. PNEUMOTHORAX
Tension pneumothorax
-Diagnosis: tracheal deviation, unilateral absent breath sounds, tympany, and
distended neck veins
-Treatment: insertion of a large-bore needle into the second intercostal space at the
midclavicular line to allow immediate decompression, then placement of a chest
tube
Open pneumothorax
-Diagnosis: sucking chest wound
-Treatment: occlusive dressing not taped on one side to allow air to escape,
followed by surgical wound closure and a chest tube

10. Flail chest with pulmonary contusion
• Diagnosis: paradoxical movement of the chest wall with ventilation
• Treatment: fluid resuscitation (beware of overhydration), intubation,
positive end-expiratory pressure may be necessary
Hemothorax
• Diagnosis: opacity on chest radiograph, diminished/absent breath
sounds
• Treatment: chest tube placement

11. INDICATIONS FOR INTUBATION
• Loss (or anticipated loss) of airway control
• Prevention of aspiration in an unconscious patient
• Hyperventilation for increased intracranial pressure
• Obstruction from facial trauma and edema

12. CIRCULATION
• Hemodynamic stability is defined as normal vital signs (blood
pressure, heart rate) that are maintained with only maintenance fluid
volumes.
• In trauma patients, shock is hemorrhagic until proven otherwise.
• At a minimum, two large-bore intravenous lines should be placed in
the antecubital fossae or groin with avoidance of injured extremities.
• Alternatively, saphenous vein cutdowns may be used in adults or
intraosseous (tibia) infusion for children

13. INITIAL MANAGEMENT OF THE PATIENT IN
SHOCK
• Direct control of obvious bleeding: direct pressure control preferable
to tourniquets or blind clamping of vessels
• Large-bore venous access, fluid resuscitation (normal saline or Ringer’s
lactate), monitoring of urine output, central venous pressure, and pH
• Blood replacement as indicated by serial hematocrit monitoring
• Traction with Thomas splints or extremity splints to limit hemorrhage
from unstable fractures
• Consideration of angiography (with or without embolization) or
immediate operative intervention for hemorrhage control

14. DIFFERENTIAL DIAGNOSIS OF HYPOTENSION
IN TRAUMA
• Cardiogenic Shock
• Neurogenic Shock
• Septic Shock
• Hemorrhagic Shock

15. DISABILITY (NEUROLOGIC ASSESSMENT)
• Initial survey consists of an assessment of the patient’s level of
consciousness, pupillary response, sensation, and motor response in
all extremities, rectal tone, and sensation.
• The Glasgow Coma Scale -assesses level of consciousness, severity of
brain function, brain damage, and potential patient recovery by
measuring three behavioral responses: eye opening, best verbal
response, and best motor response.
• A revised trauma score results from the sum of respiratory rate,
systolic blood pressure, and Glasgow Coma Scale and can be used to
decide which patients should be sent to a trauma center

16. EXPOSURE
• It is important to undress the trauma patient completely and to
examine the entire body for signs and symptoms of injury

17. RADIOGRAPHIC EVALUATION
C-spine should not be cleared without imaging if any of the following NEXUS criteria are present (N Engl J Med
2001):
1. Posterior midline cervical tenderness
2. Neurologic deficit
3. Painful distracting injuries (that hinder the reliability of questioning and examination)
4. Altered level of alertness
5. Evidence of intoxication
• In cases where C-spine imaging is needed, CT scanning has replaced conventional radiography. MRI may be
necessary to rule out disc herniation, epidural hematoma, spinal cord compression, and ligamentous injurie
• Anteroposterior (AP) chest is required.
• AP pelvis when the mechanism of injury suggests.
• CT scanning of these various regions is used as an adjunct to the primary survey.
• FAST (ultrasound of abdomen) screen for intra-abdominal blood has replaced DPL when available.

18. STABILIZATION
The stabilization phase occurs immediately following initial
resuscitation and may encompass hours to days, during which medical
optimization is sought. It consists of:
• Restoration of stable hemodynamics
• Restoration of adequate oxygenation and organ perfusion
• Restoration of adequate kidney function
• Treatment of bleeding disorders

19. DEEP VENOUS THROMBOSIS
• Risk of deep venous thrombosis is highest in this period and may be as high as 58%
in multiply injured patients.
• Highest risk injuries include spinal cord injuries, femur fractures, tibia fractures,
and pelvic fractures. A high index of suspicion must be followed by duplex
ultrasonography.
• Low-molecular-weight heparin in patients without risk factors for hemorrhage has
been shown to be more effective than sequential compression devices in
preventing thrombosis. It is contraindicated in patients at risk for hemorrhage,
especially following head trauma. Prophylaxis should be continued until adequate
mobilization of the patient out of bed is achieved.
• Vena caval filters may be placed at time of angiography and are effective in patients
with proximal venous thrombosis. Removable filters are effective and available.

20. DECISIONS TO OPERATE
• Most patients are safely stabilized from a cardiopulmonary perspective within 4 to 6 hours
of presentation.
• Early orthopaedic operative intervention is indicated for
1. Femur or pelvic fractures, which carry high risk of pulmonary complications (e.g., fat
embolus syndrome, ARDS)
2. Active or impending compartment syndrome, most commonly associated with tibia or
forearm fractures
3. Open fractures
4. Vascular disruption
5. Unstable cervical or thoracolumbar spine injuries
6. Patients with dislocated joints of the shoulder, elbow, wrist, carpus, hip, knee, ankle,
hindfoot, and midfoot that are irreducible in the emergency department (ED)

21. THANK YOU