The management of a polytraumatised

THE MANAGEMENT OF A POLYTRAUMATISED PATIENT

PRESENTING AT THE EMERGENCY DEPARTMENT

DR BASSEY A E

DEPARTMENT OF ORTHOPAEDICS

OUTLINE• Introduction

• Definitions• Epidemiology• Statement of importance

• Aetiology• Mechanisms of injury• Management

• Primary survey and resuscitation• Secondary survey• Definitive treatment

• Complications• Early• Late

• Polytrauma in special populations• Children• Elderly• Pregnant

• Current trends• Conclusion

INTRODUCTION - Definitions

• Trauma – the exchange of energy between the body and it’s environment exceeding it’s resilience and leading to injury

• Significant trauma – is an injury which by virtue of it’s location, extent, past or existing complications, present or impending haemodynamic instability will require hospital admission and treatment

INTRODUCTION - Definitions

• Polytraumatised patient – is one who has suffered 2 or more significant injuries to 2 or more organ systems

• Emergency room – is a section of a healthcare facility specializing 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 either by ambulance or their own means

INTRODUCTION – Epidemiology of trauma

• Commonest cause of death in 1-44yrs• 3rd commonest cause of death overall• Trauma mortality – >90% of trauma mortality in low and middle

income countries– 50% in 15-44yrs– M:F = 2:1– RTA commonest cause

INTRODUCTION – Epidemiology of trauma

• In Nigeria,• Prevalence – 11.2/100,000• Age – 27+/- 13yrs• Sex – M:F = 2:1• Trauma mortality– Avg age – 29.5yrs– M:F = 2.5:1– RTA – 75%– Polytrauma – 60.9%

INTRODUCTION - Statement of importance

• Trauma is a public health problem of epidemic proportion, and from data just supplied, mortality is more associated with polytrauma than isolated injury.

• Judicious application of in-depth knowledge and well-honed skills is mandatory in order to curb its devastating effects on individuals and society.

AETIOLOGY

• RTA• Fall from height• Assault• Terrorism• Natural disasters• Conflict

MECHANISMS OF INJURY

• Blunt– RTA commonest cause– Severity factors – mass & speed of vehicle, type of

vehicle, use of restraints, ejection from vehicle, interaction with vehicle parts

• Penetrating– Severity factors – mass & velocity of missile, viscera in

path of missile• Blast• Crush• Thermal

MECHANISMS OF INJURY• Trimodal pattern of death following trauma• Immediate death

(50%) – 0-1 hr(massive head inj.)

• Early death(30%) – 1-3 hrs(chest inj, exsanguinatn)

• Late death ( 20%) – 1-6 wks(sepsis, org failure)

MANAGEMENT

• Multidisciplinary • Orthopaedic surgeon• General surgeon• Anaesthetist• Trauma nurse• Radiographer • Other subspecialties, as needed

• Time is of essence• Golden hour concept

MANAGEMENT

• Aim of management

‘To return patient to pre-injury status or as near as possible’

• Scale of priorities• Save life• Save limb• Save looks

MANAGEMENT

• ATLS– Developed in USA– Adopted globally

• ATLS philosophy

Treat lethal injuries first

Reassess

Treat again

MANAGEMENT

• Primary survey and resuscitation– Identify and treat what is killing the patient.

• Secondary survey– Proceed to identify other injuries.

• Definitive treatment– Develop a definitive management plan

MANAGEMENT - Primary survey and resuscitation

• A – airway and cervical spine protection• B – breathing• C – circulation and control of external

haemorrhage• D – disability status• E – exposure and environmental control

Caveat – when patient has catastrophic limb haemorrhage CABCDE is practised

MANAGEMENT

• 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 immobilize

• In-line immobilization• Device combination – rigid c-collar, sandbags, head

strap

MANAGEMENT

• Airway assessment• High risk injury – TBI (commonest cause), maxillofacial

injury, neck injury, inhalational burn injury

• If conscious, elicit speech e.g. ask name. if unconscious, search for following features,

• Restlessness, sweating, cyanosis, resp. distress, noisy breathing, hoarseness of voice, stridor

• Use dorsum of hand to feel for breath

MANAGEMENT• Interventions– Carried out without extending neck

– The manoevres are carried out in a methodical fashion with the simpler ones attempted first

– It serves as a guideline, however special situations may require modification

Chin lift

Jaw thrust Finger sweep/suction

oro/nasopharyngeal airway Supraglottic airway eg LMA

tracheal intubation

surgical airway

CHIN LIFT

JAWTHRUST

Laryngeal mask airway

Endotracheal tube

Endotracheal tube in situ

MANAGEMENT• 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 BS, absent BS, noisiness

MANAGEMENT

• All polytraumatised patients should be given high concentration oxygen at 15L/min via a nonrebreathing face mask preferably

• Search for ‘lethal six’. Diagnosis is clinical.– Airway obstruction – treated as previously stated– Tension pneumothorax – cardinal signs are tracheal

deviation, hyperresonance, absent breath sounds. Treatment: needle thoracostomy then CTTD

– Open pneumothoraxtreatment: tape 3 sides of the wound leaving one side for air venting

MANAGEMENT

• Massive haemothorax – tachpnoea, decreased chest expansion, dullness, absent BS, shock

treatment – CTTD + thoracotomy• Flail chest – treatment: intubation and PPV• Cardiac tamponade – distended neck veins,

hypotension, muffled heart sounds

treatment: pericardiocentesis

MANAGEMENT• Circulation and control of external

haemorrhage• Assessment– Patient may be agitated, confused, pale,

dehydrated, cold clammy extremities, increased capillary refill time. Pulses may be rapid and thready, hypotensive, oliguric/anuric

• To identify site of haemorrhage remember,

‘Bleeding onto the floor and four more’

MANAGEMENT• Treatment – Pass 2 wide-bore iv cannulae, at same time blood is

obtained for invx. – Commence on iv crystalloids – N/S or R/L, 2L bolus

(consider intraosseous in children with difficult veins)– Control external haemorrhage by

• Pressure and elevation• Clamping and ligation• Tourniquets• Windlass technique• Quikclot or HemCon have been found to be useful

– Pass urethral catheter and commence hourly urine output monitoring after emptying bladder

– Transfuse transient and non-responders

Windlass technique

MANAGEMENT• Disability • Assessment– AVPU – quick– GCS – more detailed

• Exposure & environmental control– All clothing removed– Emergency room kept warm– All fluids and gases warmed– Warm blankets

MANAGEMENT

• Analgesia – opioids• Antibiotics• Anti-tetanus• Adjuncts

• 12-lead ECG• Pulse oximetry• Xrays (trauma series)• Other investigations – as needed

MANAGEMENT

• Re-evaluation: following primary survey and resuscitation, patient is re-evaluated and if stable secondary survey commences

MANAGEMENT – 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 or in the ICU

• ISS and MESS scores can be determined at this time as well as more complex investigations e.g. CT, MRI, angiography

MANAGEMENT

• Detailed history– AMPLE

• Head-to-toe examination proceeding in a systemic manner– Head & face – open head injury, ocular inj, csf

otorrhoea or rhinorrhoea– Neck – inspect for injury, swelling, palpate for

tenderness. Inspect c-spine starting from occiput. Palpate for tenderness, haematoma, step

MANAGEMENT• Chest – review primary survey and perform

full exam • Abdomen and pelvis – inspect for distention,

penetrating wounds, palpate for tenderness, a 4-quadrant tap or DPL may be done at this stage if haemoperitoneum is suspected. Pelvic compression test. Inspect perineum for lacerations, ecchymosis. Do DRE, and in the female a vaginal exam in addition

MANAGEMENT

• Extremities – examine for swelling, deformity, tenderness, crepitus. Note neurovascular status. Obviously deformed limbs should be reduced and immobilized using cast or traction for example

• Neurological assessment – full neurological exam and sensory or motor deficit documented, spine surgeons or neurosurgeons called in.

• Log-roll – requires at least 4people. Examine back for swellings, wounds eg gunshot. Examine spine from occiput to sacrum.

Missed injury!!??

MANAGEMENT

• Transfer for definitive care is done following secondary survey.

• Care is tailored to patient’s injuries

COMPLICATIONS• Early

• Shock• AKI• Sepsis• Tetanus• Fat embolism• DIC

• Late • ARDS• MODS• Demise

POLYTRAUMA IN SPECIAL POPULATIONS

• Children• Falls & RTA cause 90% of paediatric polytrauma• RTA commonest cause of death• Consider child abuse as a cause• Dosing of fluids and medication according to weight is

essential• Higher surface area-to-volume ratio means child is at greater

risk of hypothermia, increased emphasis on warmth• Children have increased blood loss associated with long

bone and pelvic fractures compared with adults; therefore, early splinting and stabilization are even more important

• Children initially respond to hypovolemia with tachycardia and may not drop their blood pressure until they have lost 45% of their circulating volume

• Consider early transfer to a pediatric trauma center.

POLYTRAUMA IN SPECIAL POPULATIONS

• Elderly• Elderly are less likely to be involved in trauma but are more

likely to die from it• Falls 2nd commonest cause in 65-74yrs group; commonest in

>75yrs group• Consider elder abuse as a cause• Elderly may not be able to mount a tachycardic response to

shock because of medications or reduced sensitivity to sympathetic outflow.

• A seemingly normal blood pressure might actually be dangerously low in a patient with baseline hypertension

• Fluid overload may be as dangerous as hypovolemia. Consider invasive monitoring

POLYTRAUMA IN SPECIAL POPULATIONS

• Pregnant• Trauma is commonest cause of non-obstetric M & M• Patients at high risk of pulmonary aspiration, consider

early NG tube placement & rapid sequence intubation if ET airway required• After 12 wks, foetus is vulnerable to abdominal trauma

incurred by mother, therefore fetal age assessment and viability becomes part of primary survey• Early consultation with an obstetrician-gynecologist is

recommended

CURRENT TRENDS

• Permissive hypotension

• Rise of regional trauma centres

CONCLUSION• Trauma remains the ‘neglected step-child of

modernisation’.• The burden of trauma mortality, mainly

resulting from polytrauma, rests upon us in developing nations.

• 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• Apley System of orthopaedics and fractures,

9th Ed, pp627-687• Bailey & Love short practice of surgery, 25th Ed,

pp285-298• http://emedicine.medscape.com/article/1270

888-overview#a6• http://www.scopemed.org/?mno=9087• Lateef O.A. Thanni (2011). Epidemiology of

Injuries in Nigeria—A Systematic review of Mortality and Etiology. Prehospital and Disaster Medicine, 26, pp 293-298

REFERENCES

• https://en.wikipedia.org/wiki/Emergency_department

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831976/

• https://en.wikipedia.org/wiki/Injury_Severity_Score

• https://en.wikipedia.org/wiki/Polytrauma• http://www.ncbi.nlm.nih.gov/pubmed/2239047• http://www.slideshare.net/prithwiraj2012/polytr

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