Management of the

polytraumatised patient
Dr Pat-Edi
 MANAGEMENT OF THE
POLYTRAUMATISED PATIENT

DR PAT-EDI CLEMENTINA OVILI

 Outline
• Introduction
• definition of terms
• Trauma scoring systems
• Trimodal pattern of death
• Lethal triad

• Mechanisms of injury
• Life threatening injuries
• Potentially life threatening injuries
• Pathophysiology
• Presentation
• Initial management

• ATLS
• Pre hospital care
• primary survey and its adjuncts
• Secondary survey and its adjuncts
• Definitive management
 Outline contd
• Complications-early -late
• Damage control surgery
• Current trends
• conclusion
 Definition of terms
• Trauma- is the exchange of energy between
the body and its environment exceeding its
resilience and leading to injury
• Significant trauma- is an injury which by virtue
of its location, extent, past or existing
complications, present or impending
hemodynamic instability will require hospital
admission and treatment
• Polytraumatised patient- is one who has
suffered significant injuries in two or more organ
systems with at least one being life-threatening
• Emergency room- is a section of a health care
facility specialising in the provision of acute care
to patients presenting without prior
appointment with a broad spectrum of illnesses
and injuries which may be life threatening
arriving by ambulance or their own means
• Trauma centre- a trauma centre is a hospital
equipped and staffed to provide care for
patients suffering from major traumatic
injuries such as falls, motor vehicular collisions,
or gunshot wounds.
• A trauma centre may also refer to an
emergency department without the presence
of specialised services to care for victims of
major trauma
 Epidemiology
• Commonest cause of death in 1-44yrs
• Trauma mortality->90% of trauma mortality is
in low and medium income countries
• 50% are 15-44yrs
• M>F
• RTA commonest
 Epidemiology
• In Nigeria
• Prevalence 11.2/100000
• Age -27 +/-13yrs
• M>F 2.5: 1
• RTA 75%
• Polytrauma 60.9%
 Statement of surgical importance
• Trauma is a public health problem of epidemic
proportion with mortality more associated
with polytrauma than isolated injury
• Polytrauma poses a unique challenge to the
surgeon as judicious application of in-depth
knowledge and well-honed skills is mandatory
on order to curb its devastating effects on
individuals and society
 AETIOLOGY
• RTA
• Fall from height
• Assault
• Domestic accidents
• Terrorism
• Natural disasters
• Conflict
 Pathophysiology

• The classically described lethal triad of trauma

• Hypothermia
– Cold exposure and loss of bosy heat at scene, during transport and in ER
– Rapid administration of cold fluids
– Anaesthesia and intubation
– Increases bleeding by inhibiting platelet adhesion, dysregulating clotting factors and
interfering with fibrinolysis

• Acidosis-inadequate tissue perfusion

– Lactic acidosis causing decreased activity of clotting factors
– Resp acidosis from narcotics, alcohol, tbi, flail chest, copd

• Coagulopathy
– Dilutional resuscitation related coagulopathy
– Non dilutional acute traumatic coagulopathy- activation of protein c pathway which
inhibits clotting factors v and viii and enhances fibrinolysis
 Indicators of severe injury
• Penetrating injury to the trunk
• 2 or more proximal long bone fracture
• Burns involving more than 15% tbsa
• Burns to face and airway
• Evidence of high velocity impact
– Fall more than 6m
– Crash speed >20mph
– Inward deformity of the care more than 0.6m
– Rearward displacement of the front axle
– Ejection of passenger from vehicle
– Rollover of vehicle
– Death of another passenger
– Pedestran hit at speed >20mph
 Life threatening injuries
The lethal six
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive hemothorax
• Flail chest
• Cardiac tamponade
Potentially Life threatening injuries
The hidden six
• Thoracic aortic injury
• Tracheobronchial disruption
• Myocardial contusion
• Traumatic diaphragmatic tear
• Oesophageal disruption
• Pulmonary contusion
 Trimodal pattern of death
• Injury mortality was classically described with
a trimodal distribution
– Immediate deaths at scene {50%}eg massive head injury
– Early Deaths due to hemorrhage eg chest injury (30%)
– Late deaths (20%)sepsis, organ failure
MECHANISMS OF INJURY
• Blunt- RTA is the commonest
• Severity factors- mass and speed of vehicle, type of
vehicle, use of restraints, ejection from the vehicle,
interaction with vehicle parts

• Penetrating
• Blasts
• Crush
• Thermal
 Management
• MULTIDISCIPLINARY
• General surgeon
• Orthopaedic surgeon
• Anaesthetist
• Trauma nurse
• Radiographer
• Other subspecialties as needed
• Time is of the essence
 Management
• Aim of management ‘to return patient to pre-
injury status or as near as possible’
• Scale of priorities
– To save life
– Save limb
– Save looks
• ATLS
• Developed in the USA
• Adopted globally
• ATLS philosophy
• lethal injuries first
• reassess
• Treat again
 Prehospital care
By paramedics ideally
The prehospital system ideally is set up to notify the
receiving hospital before personnel transport patient
from the scene
Emphasis is on airway maintenance, control of external
hemorrhage and shock, immobilization and immediate
transport to the appropriate facility
Paramedics are educated on triage of patients and
currently, onsite intubation of patients can be done
prior to transport
 Prehospital care goals
• Ensure safety of patient at scene
• Secure airway and support ventilation and
circulation using appropriate resuscitation
technique
• Deliver adequate analgesia to facilitate
extrication from scene
• Ensure safe transfer of patient to appropriate
trauma centre
• Alert trauma team prior to arrival
 Primary survey
• A- airway and c spine control
• B- breathing
• C- circulation and hemorrhage control
• D- disability status
• E- exposure and environmental control
• Concept of cABCDE for control of devastating
external hemorrhage
 AIRWAY
• Airway obstruction in the polytraumatised
patient results in death in a few minutes and
must be addressed immediately
• Assume c-spine injury in all polytraumatised
patients and immobilise
• Rigid neck collar with chin support, sandbags, head
strap
 Airway assessment
• High risk injury- TBI (commonest cause),
maxillofacial injury, neck injury, inhalational
burn injury
• If conscious, elicit speech eg ask for name
• If unconscious, check for
• Restlessness, sweating, cyanosis, resp distress, noisy
breathing, hoarseness stridor
• Use dorsum of the hand to feel for breath
 interventions
• Extend the neck
» Chinlift
» Jaw thrust
» Suction
» Oro/nasopharyngeal airway
» Supraglottic airway eg LMA
» Tracheal intubation
» Surgical airway
 Breathing

• Assessment
– Inspection-resp rate, shallow or gasping,
assymetry, contusion, penetrating wound, flail
segment, distended neck veins
– Palpation- tracheal deviation, tenderness,
crepitus, surgical emphysema
– Percussion- hyperresonance, dullness
– Auscultation- diminished breath sounds, absent
bs, noisiness
 Interventions

• All polytraumatised patients should be given

oxygen
• Search for the lethal six
• Airway obstruction- treated as previously described
• Tension pneumothorax- signs are tracheal deviation,
hyperresonance, absent breath sounds-needle
thoracostomy then Chest tube thoracostomy drainage
• Open pneumothorax-tape 3 sides of the wound, leaving
one side for air venting
Tension pneumothorax
• Massive hemothorax- tachypnoea, reduced
chest expansion, absent bs, shock-tx is CTTD
+thoracotomy
• Flail chest- intubation and PPV
• Cardiac tamponade- distended neck veins,
hypotension, muffled heart sounds-
pericardiocentesis
 Circulation

• Patient may be agitated, confused, cold

clammy extremities, increased capillary refill
time, pulses may be rapid and thready,
hypotensive, oliguric/anuric
• Quantify extent of bleed
 C-interventions
• Pass 2 wide bore canulae, at same time colect blood for
investigations
• Commence iv crystalloids- ns or ringers (consider
intraosseous in children with difficult access)
• Control external hemorrhage by-
• Pressure and elevation
• Clamps and ligation
• tourniquets
• Catheterise and commence hourly urine output charts
after emptying the bladder
• Transfuse transient and non responders
 Primary survey contd
• Disability-AVPU, GCS
• Exposure and environmental control
– Remove all clothing
– Keep er warm
– Warm all iv fluids
– Warm blankets
– Analgesia, antibiotics, anti tetanus
 Adjuncts
• ECG monitoring
• Pulse oximetry
• Xray trauma series
• Fast scan and efast
• Other investigations eg ABG, blood lactate
 Re-evaluate
• Re- evaluation following primary survey and
resuscitation is done and if patient is stable,
secondary survey is commenced
 Secondary survey
• This is a detailed systemic assessment of
patient to identify other injuries
• Usually done after primary survey but
sometimes may be done after surgery in the
icu
• The trauma score may be determined at this
time as well as more complex investigations eg
CT, MRI, angiography
 Secondary survey
• Detailed history- AMPLE
• Head to toe examination in a systemic manner
– Head and face- open head injury, ocular inj, csf otorrhea and
rhinorrhea
– Neck-inspect, swelling, tenderness, hematoma…start from
occiput
– Chest- review primary survey and do a full examination
– Abdomen and pelvis- inspect ofr distension, penetrating
wunds, palpate for tenderness, 4 quadrant tap or DPL may be
done
– Pelvic compression test, inspect perineum, do DRE
 Examination contd
• Extremities- examine for swelling, deformities, tenderness,
crepitus
• Note neurovascular status
• Obviously deformed limbs should be reduced and
immobilised
• Neurological assessment- full neurological exam, sensory and
motor deficit decumented, spine or neurosurgeons called in
• Log roll- at least 4 persons, examine the back for swellings,
wounds
• Examine the spine from occiput to sacrum
• Transfer for definitive care is done following
secondary survey
• Care is tailored to patients needs
 Damage control surgery
• This refers to operations performed in patients
whose condition is unstable to control
hemorrhage and limit contamination, without
completing definitive repair of all injuries
• There are 4 stages of damage control surgery
– The decision to perform DCS
– The operation
– The ICU resuscitation
– The second look/ definitive surgery
 Decision

• Absolute indications
– Base deficit >8mEq/L
– PH .>7.2
– Hypotension <90mmhg systolic
– PTT>60secs
– Operative “clinical” coagulopathy

• Early recognition of physiologic derangements eg

ph >7.21 and PTT>70 is associated with near
certain mortality
• Initial resuscitation should commence in ER and
continue in the OR
 Operation-principles

• The goal is to have a short operating time and transport to ICU for further
resuscitation
• Control hemorrhage
– Clamp or ligate bleeding vessels
– Pack the abdomen in the right and left upper quadrants and pelvis

• Control contamination
– Bowel injuries should be quickly closed or resected
– Delay definitive repair of injury including time-consuming anastomosis and ostomies

• Prevent hypothermia
• Warm operating room
– all resuscitating fluids and blood products should be warmed to 38degrees or higher
– Continuous use of warming device eg bair hugger

• Temporary abdominal closure

• angiography/ embolisation
 ICU resuscitation
• ventilatory support
• Rewarming
• Careful fluid resuscitation
 Definitive operative intervention
• Ideally performed at 24 to 36hrs later if indicators of
physiologic derangement persist
• Removal of packs with replacement if necessary
• Secondary survey of the abdomen- missed injuries at the time
of dcs are not uncommon
• Restoration of gastrointestinal and vascular continuity if
necessary
• Performance of other definitive procedures eg ostomy
placement
• Abdominal closure if possible
• Multiple second looks may be necessary
 Complications
• Early-
– Shock
– AKI
– Sepsis
– Tetanus
– Fat embolism
– DIC

• Late-
– ARDS
– MODS
– demise
 CURRENT TRENDS
• Permissive hypotension
• Rise of regional trauma centres
 Conclusion

• The burden of trauma mortality, mainly

resulting from poly trauma rests upon us in
developing countries
• Training and retraining of doctors and
healthcare professionals as well as enactment
of adequate, specific and appropriate policy
with widespread implementation of same will
go a long way in lightening this burden
•Thank you
 References

• Badoe and baja, principles and practice of surgery, 5th edition

• ATLS for doctors student course manual , 10th edition
• Damage control surgery, an overview, parkland trauma handbook, 3rd
edition
• Apley system of orthopaedics and fractures,9th edition
• Bailey and loves short practice of surgery, 25th ed,
• Emedicine.medscape reference.com/review article
• Lateef O.A thanni , epidemiology of injuries in nigeria, a systematic
review of mortality and aetiology
• http://en.ncbi.nlm.nih.gov/pubmed/2239047
• slideshare.net/management of the polytraumatised patient/basseyae