POLYTRAUMA

DR A.R.BAKA
DEPARTMENT OF SURGERY
FEDERAL MEDICAL CENTER, YOLA
PRESENTATION
INTRODUCTION
PRIMARY SURVEY
SECONDARY SURVEY
IMMEDIATE MANAGEMENT OF
MUSCULOSKELETAL INJURIES
INTENSIVE CARE AND SCHEDULED DEFINITIVE
SURGERY
CONCLUSION
INTRODUCTION
Trauma represents the ‘’major killing factor’’ in young
patients <45yrs of age
Trauma related mortality has three major causes:
1. Immediate mortality at the accident site(sudden
death) due to lethal injuries such as
o Aortic rupture with free bleeding
o Laceration of the brain stem
o Decapitating injuries
INTRODUCTION CONT.
2. Early mortality within the first few minutes to
hours(golden hrs) due to
o Compromised airways
o Tension pneumothorax
o Haemorrhagic shock as a consequence of
intraabdominal/intrathoracic bleeding and pelvic ring
disruptions with massive retroperitoneal hemorrhage
o Severe traumatic brain injury with acute cerebral edema
or
o Intracranial haematoma
INTRODUCTION CONT.
3. Late mortality within days to weeks after trauma due to
o Septic complications
o Multiple organ failure
o Untreatable increased intrcranial pressure associated
with cerebral edema.
DEFINITION: POLYTRAUMA is a syndrome of multiple
injuries exceeding a defined severity(Injury Severity
Score[ISS]>17) with consecutive systemic trauma
reactions which may lead to dysfunction or failure of
remote – primarily not injured- organs and vital
systems.
INTRODUCTION CONT.
Or it refers to trauma in which the patient suffers two or
more major injuries which may cause physiological
instability. The term was coined in military medicine,
where it is often due to gunshot or explosive injuries.
The polytrauma team consist of many specialities
including orthorpaedic surg., emergency
physicians,trauma surgeons, neurosurgeons, and other
surg. subspecialities
INTRODUCTION CONT.
Each member of the team should be familiar with the
basics of trauma resuscitation.
INITIAL ASSESSMENT AND MANAGEMENT
 Primary objective is survival
 Timing and priorities(Triage – sorting of casualities
by priority of Tx)
 Follow defined established algorithms
 Establish time dependent management phases for
trauma patient in the first 24hrs which comprise:
 Primary survey with base line diagnostics and
immediate life-saving procedures and establishing
INITIAL ASSESSMENT AND MANAGEMENT
Access to life-support systems according to the A-B-C
algorithm of ATLS protocol
- damage control surgery in patients who are not
responsive to the initial measures of resuscitation:
surgical control for exsanguinating hge and
decompression of body cavities(life saving surgeries)
- Secondary survey in hemodynamically stable patients
with elaborate diagnostics including a ‘’head to toe’’
examination and further radiologic work-up(CT scan,
conventional x-rays,angiography,etc)
INITIAL ASSESSMENT AND MANAGEMENT
Delayed primary survey; decontamination,surgical
exploration and Mx of non-immediately life-
threatening injuries,temporary fracture fixation
PRIMARY SURVEY
During the primary survey, the injured patient is
rapidly assessed according to the algorithm of the
ATLS protocol and life preserving therapy is instituted
simultaneously
The Tx priorities are based on the likelihood of a pat
to die within a short time from a life-threatening
injury, according to the ‘’A-B-C-D-E’’ mnemonic
The 1* survey must be repeated anytime a patient’s
status changes
PRIMARY SURVEY CONT.
Airway (with cervical spine protection)
An obstructed airway is one of the most immediate and
deadliest threat to life
Goals to provide a patent airway
Maintain in-line cervical stabilisation
Protect airway from future obstruction by
blood,edema,vomitus,other possible causes of blockade
Anticipate potential problems
Check gag reflex(ability to protect airway)
PRIMARY SURVEY CONT.
Airway Mx
Jaw-thrust maneuver may be necessary(base of tongue
usually obstructs)
Chin-lift manuever(dangerous in trauma pat may
exacerbate c spine injury)
Remove foreign bodies seen
Suction to remove secretions and blood
Orapharyngeal airway in unconscious pat
Nasopharyngeal in partially conscious pat
Laryngeal mask airway as a rescue airway
PRIMARY SURVEY CONT.
Definitive airway Mx
Achieves airway patency,protects the lungs from
aspiration, allows for positive preesure ventilation
OROTRACHEAL INTUBATION is the criterion standard
for airway Mx – an endotracheal tube
NASOTRACHEAL INTUBATION for spontaneously
breathing pat. C/I in facial fractures,basilar fractures
SURGICAL AIRWAY is a last resort. When orotracheal
has failed,obstruction of trachea by blood/edema is
complete,totally transected airway
 Cricothyroidotomy
PRIMARY SURVEY CONT.
Adjuncts to orotracheal intubation
Fibreoptic intubation
Retrograde intubation
Light wand
PRIMARY SURVEY CONT.
Cervical spine protection
In-line stabilization maintained for pat with suspected or
confirmed c-spine fracture
Mechanism of injury considered to predict danger to c-spine
Hx of ability to walk or move all 4 limbs following an injury does
not rule out the possibility of unstable c-spine fracture
Pat with facial injury,significant blunt trauma,neurologic deficit
must be assumed c-spine injury until proven otherwise
Protection provided by holding the head in neutral position
facing forward. It ca be secured with a hard cervical collar.
When intubating, in c-spine injury,maintain neutral position.
Exclude spinal cord injury clinically or radiologically
PRIMARY SURVEY CONT.
BREATHING
Any immediate life threatening obstacles to breathing,
namely tension pneumothorax,open pneumothorax,flail
chest ,or massive hemothorax must be diagnosed and Tx
quickly
Watch pat breath
Listen to the lungs
Bilatral chest expansion
Look for cyanosis
PRIMARY SURVEY CONT.
Monitor pulse oximetry- can be unreliable in
peripheral poor perfusion
Arterial blood gases maybe indicated
TX
O2 at 6-10L/min via nonrebreathing face mask to all
polytrauma pat
Ventilate pat
Tx open pneumothorax,tension pneumothorax,flail
chest,massive hemothorax
PRIMARY SURVEY CONT.
OPEN PNEUMOTHORAX(sucking chest wound)
Chest wound with diameter >2/3rds of trachea can
become sucking
Air moves preferentially through the wound and
ipsilateral lung deflates
Tx – bandage taped on both sides so air can escape but
cannot be sucked into the chest
Follow by tube thoracostomy
PRIMARY SURVEY CONT.
TENSION PNEUMOTHORAX
Deadly condition
Allows air into into interpleural space but does not escape
Lung collapse
Mediastinum pushed into opposite hemithorax
A clinical diagnosis:
 Chest pain
 Respiratory distress
 Shock refractory to fluids and pressors
 Decreased breath sounds and tympany of the affected lung
 Jugular venous distention
 Cyanosis
 Tracheal deviation to opposite side
PRIMARY SURVEY CONT.
Suspect tension pneumothorax in pat who is hypoxic
or in shock, esp if crepitus,evidence of trauma to
ipsilateral chest wall
Tx – 16-gauge needle inserted into the 2nd intercostal
space in the midclavicular line
Quikly followed by chest insertion into the 5th ICS in
the midclavicular line to reexpand the lung
PRIMARY SURVEY CONT.
FLAIL CHEST
3 or more consecutive ribs fractured at 2 sites
May result in significant morbidity and mortality
Causes hypoventilation
Paradoxical breathing may be observed
Maintain a high index of suspicion in any thoracic injury
Begin Tx immediately
Confirm diagnosis as soon as possible with CXR
PRIMARY SURVEY CONT
Tx – maximize oxygenation of lungs using PPV
Effective pain control – opiates , nerve block,
Judicious fluid mx
PRIMARY SURVEY CONT.
MASSIVE HEMOTHORAX
Can cause problem with breathing and circulation
1500ml of blood in the chest cavity
Caused by disruption of a systemic or hilar vessel
Chest can accommodate the entire circulating volume of
blood
Hemorrhagic shock maybe severe
PRIMARY SURVEY CONT.
CIRCULATION AND HEMORRHAGE CONTROL
Markers for adequate circulation:
 Level of consciousness
 Skin temperature and color
 Nail bed capillary refill time
 Rate and quality of the pulses
Control external bleeding with pressure
Log roll of pat to identify posterior bleeding
Cardiac and BP monitoring
Draw blood for laboratory studies,Hct(pcv),PT
PRIMARY SURVEY CONT.
Resuscitate with 2 large bore(14-16-gauge)IV catheters
using warm fluids and packed RBCs
Control hemorrhage
Tx cardiac tamponade,cardiac arrest,massive
hemothorax
Consider resuscitative thoracotomy
Nurse pregnant pat in Lt recumbent position
PRIMARY SURVEY CONT.
Fluid and blood resuscitation
Hemorrhage control
FAST
DPL
Tibia fracture ~750mls, femur fracture~ 1500mls of
blood loss
Pelvic fracture ~ several liters, may require
laparatomy ,CT,angiography. Use of skeletal traction in
hemipelvic displacement
PRIMARY SURVEY CONT.
Cardiac tamponade
Hemopericardium prevents diastolic filling of the heart and HF
Classic signs are Beck’s triad:
 Hypotension
 Venous distension
 Muffled heart sounds
Kussmaul sign-increased jugular venous pulsation on inspiration
Pulsus paradoxus
Cx-ray-globular heart
Unstable pat requires urgent thoracotomy
In stable pat diagnosis by
 Echocardiography
 Pericardiocentesis

Subxiphoid pericardiotomy is both diagnostic and therapeutic

PRIMARY SURVEY CONT.
Cardiac arrest
Any pat without pulse should be assessed with defibrillator
paddles or cardiac monitor
Tx unstable arrhythmias with electrical cardioversion
Resuscitative thoracotomy
Loss of vital signs in penetrating chest injuries
Tx cardiac tamponade
Gain direct control of intrathoracic hemorrhaging vessel
Perform open cardiac massage/defibrillation
Cross-clamp the aorta to slow blood loss distally and increase
perfusion to the heart and brain promimally
PRIMARY SURVEY CONT.
DISABILITY
Perform a quick neurologic exam
Level of consciousness
Pupillary size and reaction
Gross motor functioning
GCS
Altered level of conscousness maybe due to:
 Intoxication
 Hypoxia
 Hypotension
 Cerebral injury
 Hypothermia/hyperthermia
 hypoglycemia
PRIMARY SURVEY CONT.
EXPOSURE/ENVIRONMENTAL CONTROL
Expose pat by removing clothes
Control hypothermia
SECONDARY SURVEY
The secondary survey san only begin after the
resuscitative measuers of the primary survey are
completed according to the A_B_C_D_E algorithm
and pat has been hemodynamically stabilized and
demonstrate normal vital functions.
The sec sur is a head-to-toe examination designed to
identify any injuries that might have been missed.
Constant reevaluation to identify trends in physical
examination and laboratory findings.
PRIMARY SURVEY CONT.
Tx – evacuation of blood with a large bore (36-40F)
chest tube
Possible autotransfusion
 intravascular volume replaced IV with fluids and
blood
Thoracotomy maybe required to control bleeding
vessel
SECONDARY SURVEY CONT.
FOCUSED PATIENT HISTORY
Sec exam focused on the trauma and pertinent
information
Sx – pain,shortness of breath,other sxs
Allergies to medication
Medication taken
Past med/surg Hx
Last meal-risk of aspiration
Eventa leading up to trauma
SECONDARY SURVEY CONT.
HEAD AND SKULL EXAMINATION
Head trauma causes 50% of all trauma deaths
Should be highest priority during sec surv
Intracranial bleeding be identified by neurologic exam
and noncontrast CT
Suspect in
 Focal neurologic signs
 Altered mental status
 Loss of consciousness
 Persistent nausea and vomitigor headache
SECONDARY SURVEY CONT.
GCS
Eyes for acuity, pupillary size,extraocular movts
Fundoscopy for preretinal hges
Skull eamined for lacerations,fracture,tenderness
Signs of basilar fracture-Battle sign(bruising at the
mastoid area, raccoon eyes(oeriorbital
ecchymoses),CSF rhinorrhoea,otorrhea
SECONDARY SURVEY CONT.
MAXILLOFACIAL EXAMINATION
Look inside the mouth,nose for bleeding/haematoma
Le Fort fractures
Consider early intubation to protect the airway
SECONDARY SURVEY CONT.
NECK EXAMINATION
Trachea,pharynx/esophagus,great vessels
Consider early intubation
Consult ENT or general trauma surgeon
SECONDARY SURVEY CONT.
CHEST EXAMINATION
Thoracic injury accounts for 25% of the trauma related
mortality rate.
Inspect the chest for bruising,deformity,and motion of
the chest wall during respiration
Auscultate the heart for muffled heart sounds/murmurs
Auscultate the lungs for breath sounds
Palpate the chest forsubcutaneous emphysema
SECONDARY SURVEY CONT.
Injuries tha must be considered in the secondary
examination
Traumatic rupture of the aortaCXR(widened
mediastinum),aortography,CT angiography. Tx –
repair/interpositional graft
 Traceobronchial disruption- chest does not expand after
chestb tube insertion. Tx – bronchoscopy/repair
 Diaphragmatic rupture-CXR-bowel in thorax. Tx – insert NG
tube to decompress stomach/surgery
 Blunt cardiac injury-ECG,US. Tx-consult cardiothoracic
specialist
SECONDARY SURVEY CONT.
Pulmonary contusion-CXR opacities. Tx-fluid
restriction,oxygen,analgesia
Simple pneumothorax-can develop into tension
pneumothorax,esp if intubation and PPV are used. Tx-
chestb tube
Hemothorax – may become massive hemothorax, may
clotand cause long entrapment or become an empyema.
Tx-chest tube
Mediastinal traversing wounds-this may damage the
heart,great vessels,tracheobronchial tree,esophagus. Tx-
operating room/bronchoscopy,endoscopy
SECONDARY SURVEY CONT.
ABDOMINAL EXAMINATION
Blunt/penetrating trauma
FAST/DPL
CT scanning
SECONDARY SURVEY CONT.
SPINAL CORD/CERTEBRAL COLUMN
Palpate every spinous process for point tenderness
Spinal radiography to evaluate damage
Hypotension and slow pulse should be assessed for
neurologenic shock and a high spinal cord injury
Complete neurologic examination
SECONDARY SURVEY CONT.
Cervical spine clearance
No focal neurological deficits
No distracting injuries,eg,gunshot wound,pelvic
fracture,long bone fracture
No intoxications,eg,alcohol,opiates
Full orientation and awareness
No midline tenderness
Perform c-spine radiograph
SECONDARY SURVEY CONT.
Genitourinary examination
Perform a rectal exam
Examine the perineum
Check for urethral/meatal blood
IMMEDIATE MANAGEMENT OF MSS
INJURIES
Palpate all joints and long bones
Assess pulses,capillary refill
Sensation
Motor strenght
Determine limb lenghts indicates
Hip fracture
Dislocation
Pelvic fracture
SECONDARY SURVEY
Splint all fracture above and below joint after
realignment of the limb
Perform immediate reduction of dislocations-
neurovascular compromise
SECONDARY SURVEY
Pelvic fractures, suspect
Appropriate mechanism of injury-high energy trauma
Pain in pelvic region
Leg length discrepancies
Destot sign(hematoma of scrotum or ing lig)
Earle sign(hematoma or tenderness along bones on
DRE)
Roux sign(asymmetry in the distances b/w the greater
tronchanter and pubic spine on each side)
SECONDARY SURVEY
Pelvic fracture cont.
Test for pelvic stability
Order AP pelvic XR
DRE-maybe the only indication of a dangerous open pelvic
fracture impinging on the rectum
Can cause damage to nerves,genitourinary sructures,rectum
Presentation of PF-shock,hypotension,bladder/urrthral
injuries
Tx – stabilization with pelvic binders/sheet,external
fixation
SECONDARY SURVER CONT
Open fractures: All open fractures are Tx initially with
Immobilization
Irrigation of wound
Debridement of devitalized tissue
Prophylactic antibiotics
Definitive debridement and stabilization-proceed to
the operating room
SECONDARY SURVEY CONT.
Soft tissue and joint injuries
Crush syndrome
Gunshot wounds
Geriatic polytrauma
Polytrauma in children
Polytrauma in pregnant patients
INTENSIVE CARE AND DEFINITIVE SURGERY
ICU transfer is aimed at further stabilization of
polytrauma patient and for restoration of the following
end points of resuscitation
Stable hemodynamics without need for
vasoactive/inotropic stimulation
No hypoxemia,no hypocapnia
Serum lactate ≤2mmol/l
Normal coagulation
Normthermia
Urinary output>ml/kg/h
INTENSIVE CARE AND DEFINITIVE SURGERY
The pathophysiological phase of hyperinflammation b/w days 2-4 after
trauma is a time period of enhanced susceptibility to a ‘’second-hit’’
injury and thus does not allow surgical intervention
Physiological window of opportunity b/w days 5-10 after trauma. Fully
resuscitated pat is a candidate for changes in operative strategies and
definitive scheduled surgical procedures,eg, change from external to
internal fixation of long bones and pelvic ring #s,skin grafting,etc
2nd week preiod after trauma-phase of immunosuppression- no
surgery should be performed due to the susceptibility of a ‘’second-hit’’
Only after the 3rd week should further reconstructive operation be
performed, if required,eg, secondary cancellous bone graft,definitive
orthorpaedic reconstructive interventions
CONCLUSION
The complex Mx of polytraumatized patients can be
optimised by standardized and validated approaches using
well-established algorithms, such as the ATLS program
New concepts in recent years have demonstrated highly
critical polytrauma pat ‘’in extremis’’ have a significantly
improved overall outcome due use of ‘’damage
control’’surgery
The kinetics of the physiological response to severe injury
must be taken into account for the timing and priorities of
surgical interventions in the further course after trauma
CONCLUSION CONT.
This golde balance b/w mandatory primary and
secondary measures and the knowledge of the
pathophysiological reactions inadherence with
established diagnostic and therapeutic algorithms will
help improve the overall outcome of polytrauma
patients.
THANK YOU