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POLYTRAUMA

Objectives
Prioritize and initiate assessment of the
traumatized patient
Initiate treatment of life-threatening
traumatic injury
Utilize radiography in identifying
significant traumatic injury
Identify and respond to changes in
status of the injured patient
Identify patients requiring transfer to a
higher level of care

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 III
SKELETAL INJURY.
UNSTABLE PELVIS FRACTURE WITH ASSOCIATED
VISCERAL INJURY.

Polytrauma is not synonym of multiple fractures.


Multiple fractures are purely orthopaedic problem as there is
involvement of skeletal system alone.

Statistics
Trimodal death distribution
First peak instantly (brain, heart, large vessel
injury)
Second peak minutes to hours (golden hour)
3rd peak weeks later of late complications and
organ failure
If preventive measures are taken 70% deaths
can be prevented, means 30% deaths are
nonsalvagable deaths

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

ATLS
TREAT LETHAL INJURY FIRST, THEN
REASSESS AND TREAT AGAIN

TRIAGE

Triage is the sorting of patients based on


the need for treatment and the available
resources to provide that treatment

Trauma Team

Case Study 1
Unrestrained man ejected after his car
collided with a large truck
Incoherent and unable to clear secretions
Femur fracture, scalp laceration, chest and
abdominal contusions
BP 90/60 mm Hg, HR 125/min, RR 35/min
Lethargic with cool, clammy skin

What does the primary survey indicate?

Trauma Management
Primary assessment
Initial evaluation and resuscitation
Secondary assessment
Diagnosis and treatment of other
injuries
Tertiary assessment
Ongoing evaluation

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Primary Assessment
Airway maintenance with cervical spine
precautions
Breathing: oxygenation and ventilation
Circulation with hemorrhage control
Disability: brief neurologic examination
Exposure/environment: undress, avoid
hypothermia
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Case Study 1

Incoherent, unable to clear secretions

Femur fracture, scalp laceration, chest


and abdominal contusions

BP 90/60 mm Hg, HR 125/min,


RR 35/min

No eye opening to stimuli, lethargic,


all extremities withdrawn to pain

Cool, clammy skin

A
B
C
D
E

What interventions are most important?


What does the primary survey indicate?
Copyright 2012 Society of Critical Care Medicine

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Airway and Breathing Issues


Establish airway patency
Airway control: intubation, adjunctive
device, surgical airway
Oxygenation and ventilation
Cervical spine stabilization

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Airway Interventions

Supplemental oxygen
Suction
Chin lift/jaw thrust
Oral/nasal airways
Definitive airways
RSI for agitated patients with c-spine
immobilization
ETT for comatose patients (GCS<8)

Flail Chest

Subcutaneous Emphysema

What would we do for this


patient who is having difficulty
breathing?

Case Study 1
Incoherent, unable to clear secretions
Femur fracture, scalp laceration, chest
and abdominal contusions
BP 90/60 mm Hg, HR 125/min,
RR 35/min
No eye opening to stimuli, lethargic, all
extremities withdrawn to pain

A
B
C
D
E

Cool, clammy skin


Is this patient in shock?
What interventions are indicated?

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Shock in Trauma
Hemorrhagic
Chest
Abdomen
Pelvis
Femur
Nonhemorrhagic
Obstructive: tension pneumothorax,
cardiac tamponade
Neurogenic: spinal cord injury
Cardiac: blunt injury
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C- Circulation
Hemorrhagic shock should be assumed in
any hypotensive trauma patient
Rapid assessment of hemodynamic status
Level of consciousness
Skin color
Pulses in four extremities
Blood pressure and pulse pressure(narrow)

Haemorrhage

Hemorrhage Classification
BP 90/60 mm Hg, HR 125/min, RR 35/min
Variable

Class I

Class II

Class III

Class IV

HR, beats/min

<100

>100

>120

>140

RR, breaths/min

14-20

20-30

30-40

>35

anxious

agitated

Blood loss (mL)

<750

750-1,500

1,5002,000

>2,000

Blood loss (%)

<15

15-30

30-40

>40

Systolic BP

Mental status

Resuscitation
fluid

Oral or Crystalloi
d
crystalloid

confused lethargic

Crystalloi
d and
Blood and
crystalloid
blood

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Circulation Issues
Large bore peripheral IV cannulas (2) or IO
2 L warmed lactated Ringer solution (>50
mL/kg)
External hemorrhage control
Diagnostic studies for hemorrhage source
Red blood cell transfusion
Transfusion of other blood products
Monitoring

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Pelvic Binders

Case Study 1
Incoherent, unable to clear secretions
Femur fracture, scalp laceration, chest
and abdominal contusions
BP 90/60 mm Hg, HR 125/min,
RR 35/min
No eye opening to stimuli, lethargic,
all extremities withdrawn to pain
Cool, clammy skin

A
B
C
D
E

How would you assess disability?


What adverse effects occur from exposure?

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Glasgow Coma Scale


Score
1

Eye Opening
No
Response

To Pain

To Speech

Spontaneous

Best Verbal

Best Motor

No
Response

No Response

Incomprehen
Extensor
-sible
Inappropriate
Flexor
Disoriented
Oriented
GCS = 7

Withdraws to
Pain
Localizes Pain
Obeys

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Always Inspect the Back and


Perineum

Extradural Hematoma(EDH)

What disease process does this


indicate?

Case Study 1
Patient is intubated and mechanically
ventilated with 100% O2
Coarse rhonchi bilaterally
2 L lactated Ringer solution
administered
BP 104/78 mm Hg, HR 110/min, RR
18/min, SpO2 95%
What are the next steps in assessment?
Which laboratory and radiologic
tests should be obtained?

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Secondary Assessment

Detailed history
Head-to-toe physical examination
Laboratory studies
Radiologic studies
Other interventions

FAST
Diagnostic peritoneal lavage
Naso- or orogastric tube
Antibiotics
Tetanus status

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Case Study 2
Man with liver and mesenteric
lacerations from vehicular accident
Bowel resected and abdomen packed
to control bleeding
Fluid resuscitation continues
Airway pressures and urine output
after ICU admission
What are possible causes of airway
pressures and urine output?

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Tertiary Assessment
Head injury
Pulmonary injury
Cardiac injury
Abdominal injury
Musculoskeletal injury
Adequacy of resuscitation
Transfer
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Golden Rules of Trauma


All trauma patients need oxygen until proven
otherwise.
All trauma patients are bleeding until proven
otherwise.
All trauma patients have a cervical spine
injury until proven otherwise.
All unconscious/altered LOC trauma patients
have a brain injury until proven otherwise.

Conclusion
Readiness, hyper-vigilance, consistent
organization and clear cut communication
produces effective outcomes
We should all know our A, B, C, Ds
Practice makes perfect
The success of a trauma resuscitation is only
as good as its team AND
A proficient trauma team cannot function without
a well-skilled trauma nurse!