POLYTRAUMA

Mafalda Sousa
Erasmus student – Tor Vergata
Anesthesiology
Rome, June 2022
 Polytrauma
Definition: two or more severe traumatic injuries to at least two areas of the body, of which at least one or the sum of all injuries
is life-threatening

We should suspect major trauma in:

• Motor vehicle collisions 
• Death of another individual in the same collision
• Pedestrians run over by a vehicle
• Blast injuries (explosions)
• Falls from heights (attempted suicide)

• Subdural and epidural hematomas

• Lacerations of the brain, spinal • Hemopneumothorax
cord, heart, aorta, and large blood • Ruptured spleen • Sepsis and multiple organ system failu
vessels • Lacerations of the liver
• Pelvic fractures
• Blood loss
 Severity scores

Revised trauma score (RTS)

• The most used as a triage tool and as a predictor of mortality

• This score is based totally on physiologic alterations on initial evaluation:
A) Respiratory rate
B) Systolic blood pressure
C) Glasgow Coma Scale

Application of these components to the pediatric population is difficult and

inconsistent

Pediatric trauma score (PTS)

• PTS<8 : children should be triaged to pediatric

trauma center
 Triage
sorting of patients based on the need for treatment and the available resources to provide that treatment

Two types of triage situations usually exist:

Level 1 Criteria Multiple Casualties
• The number of patients and the severity of their
injuries do not exceed the ability of the facility to
respond
• Patients with life-threatening problems and those
Level 2 Criteria
sustaining multiple-system injuries are treated first.
Mass Casualties
• The number of patients and the severity of their
injuries exceed the ability of the facility to respond
Level 3 Criteria
• Patients with the greatest chance of survival,
requiring the least expenditure of time, equipment,
supplies, and personnel, are managed first.
 Clinical Approach

Five underlying principles of trauma approach:

1. Treat the greatest threat to life first
2. Lack of a definitive diagnosis should never stop treatment
3. Injury kills in certain reproducible time frames - time is key
4. Physiologic approach - ABCDE
5. Do no further harm
Treatment of all patients with major trauma passes through the same phases:
1. Primary survey (ABCDE)
done simultaneously
2. Resuscitation phase
3. Secondary survey
4. Definitive care phase
Frequently re-evaluate patient’s problems and response to treatment.
Any deterioration needs a return to evaluate the ‘ABC’ (airway, breathing,
and circulation).
 1. Primary survey
2. Resuscitation phase

A – AIRWAY AND CERVICAL SPINE

1. ASSESSMENT
Airway patency/ obstruction
Cervical spine protection
2. RESSUSCITATION
Establish patent airway
• Chin lift / jaw thrust
• Clear foreign bodies
• Oro or nasopharyngeal airway
• Definitive airway (intubation/
cricothyroidotomy)
Mantain cervical spine in neutral
position

Assume a cervical spine injury in any patient with multisystem trauma,

especially with an altered level of consciousness or a blunt injury
above the clavicle!

B – BREATHING
1. ASSESSMENT
Rate and depth of respirations
Inspect neck and chest
• Tracheal deviation
• Use of acessory muscles
Percuss and auscultate chest
1. Primary survey
2. Resuscitation phase
2. RESSUSCITATION
Ventilate and oxygenate
• High concentration O2
• Ventilate with a mask device
• Alleviate tension
pneumothorax
• CO2 monitoring device with
endotracheal tube
• Pulse oxymeter
 1. Primary survey
2. Resuscitation phase

C – CIRCULATION
1. ASSESSMENT 2. RESSUSCITATION
Identify sources of external and Stop bleeding and replace volume
internal bleeding • Direct pressure to external
bleeding
Pulse: quality, rate, regularity, • Operative intervention if
paradox internal bleeding
• 2 large caliber IV catheters
Skin color • Obtain blood for analyses and
pregnancy test
Blood pressure • IV fluid therapy (warmed
Ringer’s lactate and blood
replacement)
• Pneumatic antishock garment
(hypotension and pelvic
fractures)
• Prevent hypothermia

D – DISABILITY
1. ASSESSMENT
Brief neurologic examination
(determine level of
consciousness): AVPU, GCS
A Alert
V Responds to Vocal stimuli
P Responds only to Painful
stimuli
U Unresponsive to all stimuli
Glasgow coma scale
Assess the pupils for size,
equality, and reaction
1. Primary survey
2. Resuscitation phase
2. RESSUSCITATION
• Need for immediate
reevaluation of the patient’s
oxygenation, ventilation, and
perfusion status
• Immediate consultation with
the neurosurgeon
 1. Primary survey
2. Resuscitation phase

E – EXPOSURE/ENVIRONMENT
1. ASSESSMENT 2. RESSUSCITATION
• Completely undress • IV fluids should be warmed up
before
• Prevent hypothermia • Early control of bleeding
minimizes hypothermia
3. Secondary survey

Complete history and physical examination, including a

reassessment of all vital signs
• AMPLE History and Mechanism of Injury
Allergies
Medications currently used
Past illnesses/Pregnancy
Last meal
Events/Environment related to the injury

Diagnostic tests: • Each region of the body is completely examined

• X-rays (spinal, extremities) • Head and maxillofacial

• CT of the head, chest, abdomen, spine • Cervical spine and neck

• Contrast urography • Chest and abdomen

• Angiography • Perineum/rectum/vagina

• Transesophageal ultrasound • Musculoskeletal

• Bronchoscopy / Esophagoscopy • Neurologic