LA CONSOLACION UNIVERSITY PHILIPPINES

SURGERY II

CASE DISCUSSION
ON THE INJURED
MULTIPLE
PATIENT
GROUP 4 - COURAGE
 TASKS
1. Apply the Four-step Triage Criteria
2. Assess the injuries of the patient, obtain trauma scores and prognosis
3. What is the Trauma Alert Level of this patient?
4. What maneuvers can be done in the prehospital stage? How will you clear the
patient for transport?
5. Prioritize your suggested surgical procedures/maneuvers.
6. Design a management (diagnostic and therapeutic) algorithm (include rationale for
work-ups, if any) for this patient
CASE
A 67-year-old male is brought in after a motor vehicle crash
into a stationary pole. Two other passengers died in the field;
the patient was thrown out approximately 15 feet (4.6
meters) away from the damaged vehicle. Patient is reported
to have lost consciousness for about 5-10 mins. He is taking
aspilet 80mgs, metformin 500mgs and Gliclazide 60mgs.
At the ER, he was confused but follows commands, can
swallow and verbalize. He complains of neck and nape pains
and severe pain on his right chest. Right arm is deformed
with tenderness and crepitus. Other extremities have normal
range of motion.
Vital Signs
BP 130/80 mm Hg P 122 bpm
RR 29 cpm T 37.3 C
O2 Sat 93% CRT >3 sec
All pulses intact
Flaring of the alae nasi noted. No stridor, oral injuries or
venous congestion noted in the neck. Pupils reactive to light
and accommodation.
Swelling and tenderness over right midaxillary region; chest
with crepitus, paradoxical respiration and decreased breath
sounds. No murmurs, regular rhythm.
Abdomen is globular with voluntary guarding; epigastric
tenderness with rebound tenderness on deep pressure
1. Apply the Four-step Triage Criteria.

Step One: Physiologic

Criteria
Step Two: Anatomic Criteria
Step Three: Mechanism-of-
Injury Criteria
Step Four: Special
Considerations
 Physiological Criteria
• Measure the vital signs and level of consciousness
⚬ Glasgow Coma Scale (GCS) <14
￭ GCS 14 (X)
⚬ Systolic Blood Pressure <90
￭ SBP 130 mmHg (X)
⚬ Respiratory Rate <11
￭ 12 (X)

• PROCEED TO STEP 2 (Assess Anatomy of Injury)

 Assess Anatomy of Injury – Anatomic Criteria
• All penetrating injuries to head, neck, torso, and extremities
proximal to elbow and knee
• Flail Chest
• Combination trauma with burns
• Two or more proximal long-bone fractures
• Pelvic fractures
• Limb paralysis
• Amputation proximal to wrist and ankle

• TRANSPORT TO A TRAUMA CENTER

 Mechanism of Injury Criteria:
• Motor vehicle crash
• The patient was thrown approximately 15 feet (4.6 meters) from
the vehicle.

Special Considerations:
• The age of the patient (67 years old), which may influence the
physiological response to trauma.
• The patient is taking medications (aspilet, metformin, gliclazide)
that may affect the management and response to trauma.
2. Assess the injuries of the patient, obtain trauma
scores and prognosis.
Primary Survey (ABCDE) GCS:
• Airway - no signs of airway obstruction Eye Opening = (4)
because patient can swallow and Verbal Response = confused (4)
verbalize Motor Response = follows command
• Breathing - severe pain on right chest, (6)
chest with crepitus, decreased breath E4V4M6 = 14
sounds, paradoxical respiration (flail
chest, possible rib fracture), 02 Sat 93% Revised Trauma Score:
• Circulation - CRT >3 sec (delayed), PR GCS = 14 (4)
122 (tachycardia) SBP = 130 mmHg (4)
• Disability and neurologic status - Loss of RR = 29 cpm (4)
consciousness for 5-10 mins, (+) Total = 12
3. What is the Trauma Alert Level of this patient?

Trauma alert level II

• Trauma patient >65 years old or known history of anticoagulant use
• Loss of consciousness greater than 5 minutes
• Major MVC; Separation of rider from bike
• Death of an occupant in the same vehicle
• Two or more long bone fractures (Possible right ulna with radius
fracture)
4. What Maneuvers can be done in the Prehospital
stage? How will you clear the patient for transport?

Assess scene safety prior to providing assistance and Remove the patient from dangerous
situations.
Initiate basic life support (BLS).

Perform life-saving interventions Start with primary survey ABCDE survey with simultaneous
neuroprotective measures to prevent or to minimize secondary brain Injury.

• Airway opening maneuvers -Look for signs of respiratory distress and airway impairment.
Check the airway for any foreign objects or injuries, such as burns, soot, or fractures to the
face.
• Hemorrhage control (e.g., use of tourniquets or pressure bandages)
• Spinal immobilization-Use a cervical collar to immobilize the cervical spine. When
managing airway, manually stabilize the cervical spine.
Prehospital stage

Circulation Disability Exposure

Airway Breathing

• Ensure that the • Give supplemental • Examine the entire

Provide immediate Identify life-threatening
airway is clear Oxygen patient for signs of
hemodynamic support traumatic brain injury
and patent • Asses Ventilation occult injury,
and hemostatic (TBI), begin measures to
• Look for • Perform Initial limit secondary brain
including the axilla,
measures while
intervention groin, and back.
indications of identifying sources of injury, and expedite
• identify chest definitive surgery if • Prevent and/or
respiratory bleeding, e.g., external
injuries ( Tension indicated. manage
distress and hemorrhage, thoracic
Perform Neurological hypothermia with
pneumothorax, cavity, abdominal
airway evaluation, calculate for rewarming
Flail chest cavity, thighs,
impairment. GCS, Assess pupillary techiques.
retroperitoneal space.
• stabilize cervical light response.
spine Assess motor and
sensation functions
5. Prioritize your suggested surgical
procedures/maneuvers.

• ENDOTRACHEAL INTUBATION
-Flaring of alae nasi is an indication of respiratory distress to secure clear airway and ensure adequate
oxygenation and ventilation.

• NEEDLE DECOMPRESSION
-Possible pneumothorax (flial chest and crepitus of the chest)

• ABDOMINAL CT SCAN AND EXPLORATORY LAPAROTOMY

-Globular abdomen woth voluntary guarding, epigastric tenderness with rebound tenderness with rebound
tenderness on deep palpation could be indicative if intre-abdominal bleeding.

• OPEN REDUCTION AND INTERNAL FIXATION

Right arm is deformed with tenderness and crepitus could either be fracture or dislocation. The reason for
open reduction and intrrnal fixation is crepitus is sn indication of joint involvement.
6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.
Laboratory Exams to Request
• CBC, Platelet Count
⚬ To monitor the patient’s hemoglobin and hematocrit to prevent any complications
of possible bleeding
• BUN, Creatinine, SGPT, SGOT and Electrolytes
⚬ To assess the status of his vital organs and to prevent complications of fluid and
electrolyte imbalance
• Capillary blood glucose
⚬ Because the patient is taking metformin, we will request this to measure and assess
his glucose levels immediately
6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.

Management and Diagnostics for Tension Pneumothorax and Flail Chest

Diagnostics:
• Chest X-ray - To check for tension pneumothorax, massive hemothorax or
pneumoperitoneum. To confirm and assess any sign of rib fracture as we suspect a
flail chest in the patient as shown in his PE.
• Cervical X-ray - To confirm and assess any sign of fracture causing the patient’s
neck pain.
• Pelvic X-ray - To confirm and assess any sign of fracture or dislocation
• Right Arm X-ray o confirm and assess any fracture in the right arm which was seen
to be deformed with tenderness and crepitus
 6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.

Management and Diagnostics for Tension Pneumothorax and Flail Chest

Diagnostics:
Abdominal Ultrasound
• Quick evaluation of the abdomen for free fluid areas such as subxiphoid (cardiac
tamponade), subhepatic/Morrison’s pouch (bleeding from liver), peri-splenic area
(bleeding from spleen or pelvis).

Electrocardiogram - to monitor the patient’s cardiac activity

Monitor urine output

• Insert foley catheter - oliguria is part of the criteria for shock which is one of the things
 6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.

Management and Diagnostics for Tension Pneumothorax and Flail Chest

Diagnostics:
Additional imaging
Requests for CT-scan and MRI
• Whole Abdomen CT- scan - for massive hemoperitoneum, pelvic fracture, solid organ
injury, and detection of bleeding in retroperitoneal area
• Cranial Plain CT- scan - to confirm and assess brain hemorrhage in unstable trauma patient
• MRI - If the patient is stable, best modality to evaluate spinal cord injury
.
 6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.

Management and Diagnostics for Tension Pneumothorax and Flail Chest

Management:
Pain management administer analgesics, preferably opioids to alleviate pain and improve respiratory mechanics
• Thoracic stabilization
⚬ Apply chest binder to stabilize the flail chest and prevent paradoxical chest wall movement. This will help to
improve respiratory mechanics and reduce pain, preventing respiratory compromise
⚬ Flail chest
￭ Place the patient immediately placed on 100% oxygen.
￭ If the patient is in respiratory distress despite having been placed on oxygen, consider mechanical
ventilation. Fluid resuscitation
• Should be cautiously administered to minimize fluid overload risk
• A lactated ringer's solution may be used
⚬ Tension pneumothorax
• Perform immediate needle decompression by inserting a large bore needle into the 2nd intercostal space
THANK
YOU