1. Polytrauma, or multiple trauma, refers to injuries to multiple body systems and regions resulting from severe trauma. It requires management by a multidisciplinary trauma team.
2. The document outlines the approach to polytrauma patients, including following ATLS protocols to address life-threatening injuries first through the primary and secondary surveys, resuscitation of airway, breathing, circulation, disability and exposure/environment, and then providing definitive care.
3. Key aspects of management include rapid triage, fluid resuscitation following the "3 for 1 rule", controlling hemorrhage from major sources, monitoring for shock, and ordering adjunct tests and monitoring as needed while stabilizing the patient.
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
ATLS is two days course for those who manage trauma patients. These protocols have been followed by hospitals all over the world to treat trauma patients quickly and efficiently.
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
ATLS is two days course for those who manage trauma patients. These protocols have been followed by hospitals all over the world to treat trauma patients quickly and efficiently.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. POLYTRAUMA
• World wide No.1 killer amongst the younger age group (18-44 yrs).
• Third most common cause of death in all age group.
• Great economic & social loss to country.
• TRAUMA- Neglected Disease of Modern Society
3. POLYTRAUMA
• Defined as “a clinical state following injury to the body leading
to profound physiometabolic changes involving multisystem’’.
OR,
• Patient with anyone of the following combination of injuries
• 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 fracture with associated visceral injury.
4. 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.
Polytrauma is a multi-system injury and needs management by a
team of surgeons and physicians. Orthopaedic surgeon is one of the
team member of trauma unit.
5. Objectives: Approach to polytrauma Patients
• Diagnose, initially manage and know when to immediately refer a
patient with a condition that requires urgent specialist management
• Management as per ATLS protocol
• Knowledge about in-line immobilization of cervical spine while
managing the airway
6. Objectives: Approach to polytrauma Patients
• Function of spinal board as a transfer tool only
• Emergency orthopedic conditions that affect the patient life and its
initial management; e.g. open book pelvis fracture, bilateral femur
fractures, mangled extremity
• Importance of interpersonal communication skills
7. MECHANISMS OF INJURY
Types of injury
• Penetrating
• Non-penetrating blunt
• Blast
• Thermal
• Chemical
• Others - crush & barotrauma.
8. TRIMODAL DISTRIBUTION OF DEATH
Immediate death
(50%)
0 to 1 hr
Early death
(30%)
1 to 3 hrs
Late death
( 20%)
1 to 6 wks
Golden
Hour
9.
10. Trauma deaths
First peak
• Within minutes of injury
• Due to major neurological or vascular injury
• Medical treatment can rarely improve outcome
Second peak
• Occurs during the 'golden hour'
• Due to intracranial haematoma, major thoracic or abdominal injury
• Primary focus of intervention for the Advanced Trauma Life Support
(ATLS) methodology
Third peak
• Occurs after days or weeks
• Due to sepsis and multiple organ failure
11.
12.
13.
14. LIFE SALVAGE
• 50% deaths due to trauma occur before the patient reaches hospital.
• 30% occur within 4 hrs of reaching the hospital.
• 20% occur within next 3 weeks in the hospital.
15. AIMS IN MANAGEMENT
“TO RESTORE THE PATIENT BACK TO HIS
PREINJURY STATUS”
Having following priorties:
• Life salvage
• Limb salvage
• Salvage of total function if possible
16. PHILOSOPHY FOR MANAGEMENT
ADVANCED TRAUMA LIFE SUPPORT -- based on
‘TREAT LETHAL INJURY FIRST, THEN REASSESS AND TREAT AGAIN’
The steps in management are:
•Primary survey
•Resuscitation
•Secondary survey
•Definitive care
17. TEAM APPROACH
Consists of surgeons, orthopedics, Anesthetics,nurses,radiographer
Team should have a leader and should be
• able to evaluate the patient swiftly.
• Willing to discuss the effect of the management
of one problem on other.
• Able to arrive at decisions quickly.
• Efficient in regard to performing lifesaving procedures .
18. PREHOSPITAL RETRIEVAL & MANAGEMENT
AIMS
Access of the patient
Smooth transfer
APPROACHES
Scoop & Run policy
Stay & Play policy
19. How to move unconscious casualty
• do not move the casualty unless it is absolutely necessary
• assume neck injury until proved otherwise
• support head and neck with your hands, so he can breathe freely
Apply a collar, if possible
• There should be only 1 axis (head, neck, thorax) no moving to sides,
no flexion, no extension.
• Move with help of 3-4 other people 1 support head (he is directing
others), other one shoulders and chest, other one hips and
abdomen, last one - legs.
20. Basic Emergency Medical Technician Skills
1. Maintenance of airway (endotracheal intubation?).
2. Cardiopulmonary resuscitation.
3. Intravenous access and Ringer’s lactate therapy.
4. Reduction and splintage of fractures.
5. Perform primary survey of patient and report findings to destination
PREHOSPITAL PHASE
21. TRIAGE
• Triage is the sorting of patients based on the need for
treatment and the available resources to provide that
treatment
• Ideally must be followed right from the site of the Accident
2 types usually exist
22. • The number of patients and severity of injuries do not exceed the
ability of facility to render care: in this situation , patients with life-
threating problems and those sustaining multiple system injuries are
treated first.
• The number of patients and the severity of their injuries exceed the
capacity of the facility and the staff: In this situation ,those patients
with greatest chance of survival , with least expenditure of time ,
equipments , supplies and personnel , are managed first
23. TRIAGE SIEVE – to separate dead
& the walking from the injured
TRIAGE SORT – to categorize the
casualties according to local protocols.
Cat 1 : critical & cannot wait.
Cat 2 : urgent – can wait for 30 mins at most
Cat 3 : less serious injuries.
Cat 4 : expectant – survival not likely.
24. Triage categories
Cat Definition Colour Treatment Example
P1
Life-
threatening
Red Immediate Tension pneumothorax
P2 Urgent Yellow Urgent Fractured femur
P3 Minor Green Delayed Sprained ankle
P4 Dead White
25. The 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
26. ATLS – COMPONENT STEPS
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.
27. Primary Survey
• Airway with cervical spine control.
• Breathing and ventilation
• Circulation –control external bleeding.
• Dysfunction of the central nervous system
• Exposure (undress)/Environment (temp.control)
28. PRIMARY SURVERY
During the primary survey life threatening conditions are identified and
management is instituted SIMULTANEOUSLY.
•Airway obstruction
•Tension pneumothorax
•Hemothorax
•Open thoracic injury and Flail chest
•Cardiac temponade
•Massive internal or External hemorrhage
Priorities for the care of Adult , Pediatrics & Pregnancy women are all the
same.
29. Assess Airway
• If patient is conscious airway is maintained
• Open if necessary using jaw-thrust maneuver
• Consider oro- or naso-pharyngeal airway
• Note unusual sounds and correct cause
• Snoring – oro-/naso-pharyngeal airway
• Gurgling – suction
• Stridor – consider intubation
31. DEFINITIVE AIRWAY
Cuffed tube in trachea secured thoroughly with oxygen
enriched gas supplementation.
Indications for definitive airway-
A=Airway- Obstructed airway, Inadequate Gag reflex
B=Breathing- Inadequate breathing, oxygen saturation less then 90%.
C=Circulation- systolic BP < 70 mm Hg despite resuscitation.
D=Disability-Coma, -GCS less then 8/15.
E=Environment-Hypothermia, Core temp<33degree C.
32. BREAHTING
• Airway patency does not assure adequate ventilation.
• Rate, Rhythm, Depth (tidal volume)
• Use of accessory muscles/retractions
LOOK
Cyanosis
Chest asymmetry
Tachypnea.
Distended neck veins.
Paralysis.
LISTEN
I can’t breathe?
Stridor
Wheezing
Decreased breath
Sounds.
FEEL
Chest tenderness.
Deviated trachea.
Surgical
emphysema.
33. WHEN TO VENTILATE?
• Apnoea
• Hypoventilation
• Flail chest
• High Spinal cord injury
• Diaphragmatic injury
• Head injury GCS <8
• Hypercapnia
• Hypothermia
34. *Protection of the spine & spinal cord is the important
management principle.
*Neurological exam alone does not exclude a cervical spine
injury.
*Always assume a cervical spine injury in any pt with multi-
system trauma, especially with an altered level of
consciousness or blunt injury above the clavicle.
Airway Maintenance with
Cervical Spine Protection
35. 1. cricothyroidotomy
•last resort for airway control.
•Y connector with O2 at 15 l/min.
•Intermittent jet insufflation- sedate &
paralyze, only for 30-45min.
EMERGENCY RESUSC. MEASURES TO MAINTAIN
ADEQUATE AIRWAY AND BREATHING
36. Intercostal drain
4th or 5th intercostal space,
mid-axillary line
local anaesthetic down to
pleura
‘above the rib below’
blunt dissection. finger
exploration
pass large drain on forceps
superior & posterior.
underwater drain
pursestring suture
EMERGENCY RESUSC. MEASURES TO MAINTAIN
ADEQUATE AIRWAY AND BREATHING
39. Class I Class II Class III Class IV
Blood loss (liter) Up to 0.75 0.75-1.5 1.5-2.0 > 2
% TBV 15% 30% 40% >40%
Pulse rate < 100 > 100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal or inc Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output > 30 ml/hr 20-30 5-15 Negligible
Mental status Slightly anxious Mildly anxious Anxious/confused Confused/lethargic
Fluid Replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and Blood
Classification of Hypovolaemic Shock and Physiologic Changes
Crystalloid/blood Crystalloid/blood
What is your fluid replacement regimen?
41. 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
42. CAUSES OF MAJOR BLEEDING
THE BIG FIVE:
EXTERNAL visual inspection Local Pressure
THORACIC Primary survey and
CXR .
intercostals tube
insertion
PELVIS pelvis X-ray.
Usually self
limiting/ pelvic ring
closure
LONG BONES clinical
examination.
Spontaneously
traction splintage
ABDOMEN
clinical
findings/exclusion of
other/USG/CT/DPL
Laparotomy
43. 50% of trauma death are due to head injuries
Simple method to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Glasgow Coma Scale.
DISABILITY
( NEUROLOGICAL EVALUATION)
44. Glasgow Coma Score
• If GCS < 10 CT head is indicated
• If GCS<9 intubation
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
45. Signs of Severe Head Injury
• Unequal pupils
• Unequal motor examination
• An open head injury with exposed brain tissue
• Neurological deterioration
• Depressed skull fracture
46. • Patient should be undressed to facilitate thorough
examination.
• Warm environment (room temp) should be maintained
• Intravenous fluid should be warm.
•Use forced air warming devices before and after surgery
● Use carbon polymer heating mattress
• Early control of hemorrhage
E. EXPOSURE /
ENVIRONMENTAL CONTROL
47. A.Airway
Definite airway if there is any doubt about the pt’s ability to
maintain airway integrity.
A definite airway is a cuffed tube in the trachea.
B. Breathing /Ventilation/Oxygenation
Every multiple injured pt should received supplement oxygen.
A clear distinction must be made between an adequate airway and
adequate breathing.
RESUSCITATION
48. C. Circulation
•Control bleeding by direct
pressure or operative intervention
•Minimum of two large caliber
IV(16G) should be established
• Lactated Ringer is preferred &
better if warm.
RESUSCITATION
49. Children less than 6 y/o for IV
access is impossible due to
circulatory collapse or for whom
percutaneous peripheral venous
cannulation had failed on two
attempt
Venescetion
•Greater saphenous vein 2cm ant
and superior to medial malleolus
•Antecubital medial basilic vein
2cm lateral to medial epicondyle
Intraosseous Puncture/Infusion
51. 3 FOR 1 Rule
• The total amount of crystalloid volume acutely is to replace
each ml of blood loss with 3 ml of crystalloid fluid, thus
allowing for restitution of plasma volume lost into the
interstitial & intracellular space.
• 1:1 if blood is available
52. Fluid resuscitation - DEBATE
Lethal
Triad of
Death
Acidosis
Hypothermia
Coagulopathy
Voluminous crystalloid
● dilutes coagulation factors
● causes hyperchloremic and lactate
acidosis
● supplies inadequate O2 to under-
perfused tissue
53. Current concepts
• Permissive hypotension
• Maintain systolic B.P. at 85 - 95 mm of Hg
Turn off the tap and do not infuse too much
of fluid and blood products
54. End point of resuscitation
• Stable hemodynamics
• Stable oxygen saturation
• Lactate level below 2 mmol / L
• No coagulation disturbance
• Normal temp
• Urinary output > 1ml /kg/hr
• No requirement of inotropic support
55. Focused History and Physical
AMPLE History
• A – allergies
• M – medications
• P – past medical history
• L – last oral intake
• E – events leading up to the incident
56. ADJUNCT TO PRIMARY SURVEY & RESUSCITATION
A. Electro-cardiographic Monitoring
B. Urinary catheter & Gastric tube
C. X-Ray & Diagnostic Studies
C-spine lateral , CXR, Xray Pelvis
E-FAST Scan
Essential x-ray should NOT be avoid in pregnant pt.
57. SECONDARY SURVEY
• Does not begin until the primary survey (ABCDEs) is
completed, resuscitative effort are well established & the
pt is demonstrating normalization of vital sign.
• Head to Toe evaluation & reassessment of all vital
signs.
• A complete neurological exam is performed including a
GCS score.
• Special procedure is order.
58. 7. ADJUNCT TO THE SECONDARY SURVEY
include additional x-ray and all other special
procedure.
8. RE-EVALUATION
urine output 1ml/kg/hr
9. DEFINITE CARE
59. Polytrauma in pregnant female
• Treatment 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 mother than monitor the fetus
61. 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
62. • Intensive hospital care,
• long-term rehabilitation, life-long care.
• Initial care- strict immobilization of the spine
•Complete neurologic assessment
• Steroid therapy must be initiated within a few hours of injury
• Injuries above C3- are apneic, need intubation
• between C3 and C5 – may need intubation later
• Complete transection- poor prognosis
• Preservation of remaining function
63. Pelvic injuries
• Pelvic injury is one of few bony injury that can lead to pt death
• Pelvic injuries are assesed during secondary survey
• Pelvis x ray is mandatory in polytrauma pt
• Can lead to life threatening hemorrhage
• Open pelvic # 50% mortality
• Uretheral injury : transurtheral catheter or suprapubic catheter
65. Head injury
• Traumatic brain injury (TBI)- the leading cause of death in trauma
patients- 50% of all traumatic deaths.
• Primary injury- the anatomic and physiologic disruption that occurs
as a direct result of trauma
• Secondary injury- extension of the primary injury, result from local
swelling, increased ICP, hypoperfusion, hypoxemia, or other factors.
• Aim- detection and treatment of primary injury and prevention of
secondary injury
66. Head injury management
• Maintain BP >90 mmHg, PaO2 >60 mmHg
• Assess GCS and lateralizing signs- pupil and motor function
• Pupillary asymmetry >1 mm suggests intracranial injury
• Larger pupil is on the side of the mass lesion
• Extremity weakness- detected by testing motor power
• CT scan head- accurate localization of the lesion
• Epidural or subdural hematoma causing mass effect evacuated
• Diffuse axonal injury- maintain cerebral perfusion and prevent rise in
ICP
67. Early total care (ETC)
• That is definitive fracture treatment within 24 hr
• Used in stable pts
• Avoided in severe thoracic injuries
haemorrhagic shock
head injury
• Advantages: pain relief , less infection, eary mobilization, decreased
thromboembolism
68. Damage control
• Polytrauma pts means that surgical treatments intend to
control but not to definitively repair the trauma induced
injuries early after trauma
• Used in unstable and extremis pts
69. DAMAGE CONTROL
•Stage 2: Physiological restoration in ICU.
•Stage 3: Return to operation theatre for definitive
surgery.
•Stage 1:Minimum surgery is done
• achieve haemostasis.
•Limit the contamination
•Temporary stabilisation of unstable fractures
70. Damage Control Surgery
(“STAGED LAPAROTOMY”)
•Arrest bleeding , and the resulting coagulopathy.
• Limit contamination and the sequelae .
•Close the abdomen to limit heat and fluid loss,
and to protect viscera.
71. Damage control orthopaedics
1st stage temporary stabilisation of #
2nd stage resuscitation and optimisation
3rd stage definitive fracture fixation
•External fixator is most commonly used for temporary stabilisation
•Change to definitive # fixation is done in 2nd week
73. CONCLUSION
• Favorable outcome for a critically injured patient demands an
integrated team effort.
• Initial treatment is dictated by patient’s immediate physiologic
requirement for survival.
• The definitive treatment requires rapid assessment and life
preserving therapy.
• Damage control surgery should have a defined place in surgeons
thinking.