Polytrauma

Polytrauma
Moderator-Associate prof.Dr.Mehedy Newaz.
MBBS,MS(Ortho)
Dr.Md.Shaukat Shorif
Resident,D-ortho course,
Khulna Medical College,Khulna.

Polytrauma
Defined as
“a clinical state following injury to
the body leading to profound physiometabolic
changes involving multisystems that may give rise
to a life treatening situation.”

Polytrauma
Patient with anyone of the following combination of
injuries
TWO MAJOR SYSTEMS INJURY + ONE MAJOR LIMB INJURY.
ONE MAJOR SYSTEM INJURY + TWO MAJOR LIMBS INJURY.
ONE MAJOR SYSTEM INJURY + ONE OPEN(G-III) SKELETAL INJURY.
UNSTABLE PELVIS FRACTURE WITH ASSOCIATED VISCERAL INJURY.

Epidemiology
World wide No.1 killer amongst the younger age
group (18-44 yrs).
 3rd most common cause of death in all age group.
Great economic & social loss to country.
Less than 2% of budgets for health services spend
on trauma patients.
TRAUMA- Neglected Disease of
Modern Society

POLYTRAUMA / MULTIPLE FRACTURES
 Polytrauma is not synonym of multiple fractures.
 Multiple fractures
are purely orthopaedic problem as there is
involvement of skeletal system alone. While in
 Polytrauma
there is involvement of more than one
system,like associated head/spinal injury, chest injury,
abdominal or pelvic injury.

Systemic Inflammatory Response
Trauma→cytokines↑→ activate immune system
as well as complement system
A compensatory anti-inflammatory
response→post-traumatic immunosupression

Inflammatory Markers
Interleukin(IL)-1, IL-6, IL-8, IL-10, CRP, TNF-‫ﻪ‬
Measure and monitor inflammatory response to
major trauma
IL-6 is recommended
Help orthopaedic surgeon to determine appropriate
timing of fracture fixation in severely injuried
patients

• This metabolic changes are found in the
hyperdynamic phage traumatic response of the body.
• These substances are mainly released from
endothelial and reticuloendothelial cells mainly
macrophage.

Exaggerated inflammatory response
→ Neutrophil demargination, vascular endothelium
disruption .
This endothelial damage leads to increased
microvascular permeability with the formation of
protein rich edema fluid.
 Microcirculation disturbance, tissue hypoxia leads
to parenchymal necrosis.
 SIRS, ARDS, multiple organ failure

“Two Hit “ hypothesis
Initial trauma, surgical intervention: 2 hits
Surgery performed in posttraumatic period may
increase inflammation response ( marker) and cause
multiple organ failure or ARDS.
38% of secondary surgery in multiple injuried
patients preceded a deterioration in organ function

Physiometabolic changes in Polytrauma
A)Metabolic changes
B)Circulatory changes

A)Metabolic changes
a)Early or ebb phase(24 to 48 hours):
characterized by-
 1)Decreased metabolic rate
 2)Increased release of cathecolamines
Incresed glycogenolysis in liver
Promotes gluconeogenesis in liver
Lactic acid is released from muscle & converted to glucose
in liver(Diabetes of trauma)
Lipolytic effect:fatty acid is released from adipose
tissuemetabolic acidosis

Metabolic changes cont…
b)Convelescence or High flow phase:
a)Catabolic phase:characterized by-
 Negative nitrogen balance
 Sodium & water retension
 Potassium depletion
b)Anabolic phase:
Positive nitrogen balance
Na+ & water depletion
K+ retension

Circulatory changes
3 Phases:
Phase 1:
Immediate syncope
Redistribution of available blood to vital centers
Phase 2:Restoration of blood volume
Phase 3:Replacement of red cells

TRIMODAL DISTRIBUTION OF
DEATH
 Immediate
death(50%)
Occurs within minutes
 Early death (30%):
Occurs with in 1 to 3 hrs
 Late death( 20%):
Occurs with in 1 to 6 wks
Golden
Hour

1st Peak of death
With in minutes
Severe head injury
Brain stem injury
High cord injury
Heart & major vessels injury

2nd peak of death
Intra cranial bleeding
Chest injury
Abdominal bleeding
Pelvic bleeding
Multiple limb injury

3rd peak of death
Several Days or Weeks
Sepsis
Multy organ failure
Influence by Early managemament

Trauma Care Staging
Pre-hospital care:
Organization
Safety on scene-including personal protection
Immediate action & Triage
Assessment & initial management(BLS protocol)
Transfer to hospital
Helicopters & air ambulance

Trauma Care Staging
Hospital care:
Organization:
a)Receiving hospital
b)Trauma units
c)Major trauma Centres
Trauma teams
Assessment & management-The ATLS concept
Definitive & systemic management.

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

Dr.Donald Trunky have summerized the
“GOLDEN HOUR” by 3R rules-
Right Patient to
Right Place at
Right Time

Triage
It means-to sort
Triage is the process
of prioritizing patient
treatment during the
mass casualty events.

Stages of Triage
2 Stages of Triage
Triage sieve:
Quick and uncomplicated system based on simple
clinical observation,ability to walk, breathe and
maintain peripheral perfusion.
Performed by trained, but non-clinical personnel.
Triage sort:
It requires a degree of clinical training and uses
physiological measurements to score casualties and
place them into priority groups.

Priority categories of Triage
Category 1: Immediate & Critical Red
Category 2: Urgent,can wait 30 minutes at
most
Yellow
Category 3: Delayed.Less serious injury Green
Category 4 Dead.Survival not likely White
Both triage systems place casualties into 4
colour-coded priority categories:

The Revised Trauma Score
Used in the out-of hospital setting as a tool for
trauma center triage.
 Also used as a prognostic tool for survival.
RTS utilizes 3 physiologic parameters:
Glasgow Coma Scale (GCS)
Systolic blood pressure (SBP)
Respiratory rate (RR)

The Revised Trauma Score
Glasgow
Coma Scale
(GCS)
Systolic Blood
Pressure
(SBP)
Respiratory
Rate
(RR)
RTS
Value
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0

Trauma Team
Emergency Department physician
Anaesthetist and anaesthetic technician
 Emergency Department nurses
Radiographer
General surgeon and orthopaedics surgeon
Intensive care specialists
Appropriate specialists according to needs.

Aims in Management
“TO RESTORE THE PATIENT BACK TO HIS
PREINJURY STATUS”
HAVING FOLLOWING PRIORTIES:
Life salvage
Limb salvage
Salvage of the total functions if possible

Principles of management
ADVANCED TRAUMA LIFE SUPPORT - based on
‘TREAT LETHAL INJURY FIRST, THEN
REASSESS AND TREAT AGAIN’
The steps in management are:
Primary survey with simultaneous
resuscitation:Identify & treat what is killing the patient.
Secondary survey:proceed to identify all other
injuries
Definitive care.

Primary Survey
Airway maintenance with cervical spine control.
Breathing and ventilation
Circulation –control of haemorrhage.
Disability:Neurological status
Exposure:Proper expose the patient and asses for
other injuries(exposure with environment control).

PRIMARY SURVERY
During the primary survey life threatening
conditions are identified and manage it
simultaneously.
Airway obstruction
Tension pneumothorax
Hemothorax
Open thoracic injury and Flail chest
Cardiac temponade
Massive internal or External
hemorrhage

ADJUNCTS TO PRIMARY SURVEY
Vital signs:Pulse,BP,Temp
ECG
End-tidal CO2 monitoring
Urinary output:Child:0.5 ml/kg/hr Adult:1 ml/kg/hr
Blood for CBC,RBS,Blood
urea,S.creatinine,S.electrolytes
Nasogastric tube (unless contraindicated)
Chest X-ray
Pelvic X-ray

Airway maintenance & cervical spine
protection`
Assessment of-
Patency of airway
Any airway obstruction
Check for trachea,larynx & fasciomaxillary injury

Management:
Patency of airway established by `Chin lift` or Jaw
thrust maneuver
Clean the airway(FB,Vomitus,secreation)by suction
Endotracheal intubation or tracheostomy(if needed)
Stabilize the cervical spine with neck brace,sand bag
etc(in a neutral position).

Breathing & Ventilation
Assessment of the patient-
Cyanosis
Rate & depth of respiration
Any abnormality in the chest wall movement
Position of the trachea
Chest percussion & auscultation
Check for pneumothorax,Haemothorax,# rib etc

Breathing & Ventilation
• Management:
according to the cause,i.e-
If tension pneumothoraxNeedle
decompression followed by thoracotomy
Cardiac tamponadeNeedle or open
pericardiocencenthesis
Open sucking chest:Temporary sealing or open
sucking chest followed by occlusive dressing

Circulation & control of Haemorrhage
• Assessment-
Identify the site of bleeding
Blood pressure
Carotid pulse (absent or present)
Capillary refill
Skin color
Skin temperature

Management:
Control of external bleeding by direct pressure,pack etc
Open 2 I/V channels with short wide bore I/V
cannula(16 to 18 G)
Send blood for grouping & cross matching
Start I/V fluid:Hartmann solution/Ringer`s Lactate
solution or Normal saline(Never DA)
Urinary catherization
If central pulse is absent, begin CPR

DISABILITY(NEUROLOGICAL EVALUATION)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Assessment of pupillary size and reaction
Not forget to use also Glasgow Coma Scale.

Glasgow Coma Score
 If GCS < 10 CT
head is indicated
GCS < 8 indicate
ICU support
Eye Opening
Spontaneous 4
To voice 3
To pain 2
None 1
Verbal Response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Motor Response
Obeys command 6
Localizes pain 5
Withdrawn (pain) 4
Flexion (pain) 3
Extension (pain) 2
None 1

Exposure and environment
Completely undress the patient
Warm blanket to prevent hypothermia
Examine the patient from front & back using a
careful controlled log roll.

Critical decision
Critical decision is made according to respond
of the patient
1)Respond to resuscitation:
Send the patient to ward for further resuscitation
2)Transient respond to resuscitation:
Send the patient to ICU
Non-responder:
Send the patient to OT for definative or damage
control surgery.

Medication
 Tetanus prophylaxis
 Steroids
 Inotrophic drugs
 Antiobiotics
 Calcium gluconate
 Bicarbonate

Damage control surgery
Rapid initial control of haemorrhage & contamination
& further damage with packing, temporary closure
or,followed by resuscitation in ICU and subsequent re-
exploration & definative repair & fixation once normal
physiology has been restored.

Principles
Control of haemorrhage
Identification of injury
Prevention of contamination
Avoid further injury

Stages of DCS
Stage 1:Minimum surgery is done
 achieve haemostasis.
 Limit the contamination
 Temporary closure or stabilisation)
Stage 2:
Resuscitation in ICU & correction of “Lethal triad”.
Stage 3:
Return to OT for definitive surgery.

Complication of DCS
Sepsis & multi organ failure
Pneumonia
Intra abdominal abscess
Enteric fistula
Compartment syndrome

Secondary Survey
Components:
Detail history taking(AMPLE)
A-Allergy
M-Medication
P-Past medical history
L-Last meal
E-Event of incidence
Head to toe examination
Imaging & laboratory studies
Seek for any associated injury

Definative care
A definitive treatment plane according to
cause.

Spinal injuries
• Any pt suspected of
spinal injury must be
immobilised unless spine
has been cleared
• Cervical collar
• Spine board
• Log roll technique
Log roll technique

Pelvic injuries
Pelvic fracture acounts for <5% of all skeletal injury
associaated with soft tissue injury & blood loss.
Pelvic injuries are assesed during secondary survey
Pelvis x-ray is mandatory in polytrauma pt
Mortality rate range from about 10% to 50% due to
shock,sepsis or ARDS.
Uretheral injury transurtheral catheter or suprapubic
catheter

Immediate Mx of severe pelvic bleeding
Consideration of haemodynamic status
Follow routinely ATLS protocol
Stabilization by-
Pelvic binder
External fixation
C-clamp
Pneumotic anti-shock garment
Traction
Surgical treatment generally reserve for unstable
injury by ORIF with treatment for rupture &
bladder.

Polytrauma in pregnant female
Tratement priorities are same as for non pregnant pt
Unless spinal injury is present pt should be
examined in left lateral position
Pt can loss upto 35%of blood before tachycardia and
hypotension appears
Fetus may be in shock while mother appears normal
1st resuscitate the female than monitor the fetus

MANAGEMENT OPEN PNEUMOTHORAX
Ensure adequate airway
100% oxygen
Seal open wound
IV access
Notify Medical Direction

SEALING THE OPEN WOUND
Asherman chest seal is very effective

SEALING THE OPEN WOUND
You can use impervious material taped on three sides

MANAGEMENT
TENSION PNEUMOTHORAX
Ensure adequate airway
100% oxygen
Needle decompression or water seal drainage
if indicated
IV access
Notify Medical Direction

Management of Flial chest
Patient is treated in ICU/HDU
Respiratory physiotheraphy
Serial arterial blood gas analysis
Pt needs IPPV for about 2 to 3 weeks upto flial
segment gets established.
Routine fixation of flial segment is not required

Management of Flial chest
Others general care:
 Intermittent suction
 Care of bowel & bladder
 Skin care
 Maintenance of nutrition
 Antibiotics
 Analgesic

REHABILITATION
Restoration to pre injury status
Starts with reception, ends with ambulation
Limb mobilization & postural change to prevent
subclinical DVT,pressure sores, disuse atrophy,
stiffness and contractures.
Helps to augment anabolic status

MESSAGE
Polytrauma Management
Its not only important to
Save A Life
But to ensure that
THE EFFORTS
Help the victim to end up with
Good Quality of Life
with no or minimal
Functional Disability.

Polytrauma

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