1. Approach for poly-trauma patient
Dr. Hany Victor
Lecturer of Anesthesia and ICU
ETC Instructor

2. Objectives Case presentation on poly-trauma patient.
Discussion on the case
Approach to poly-trauma patient
Recommendation
MCQ

3. Case
Male patient 28 years presented to the ER following a motor car accident 30 min ago complaining of chest pain, cut wound in the forehead with minimal bleeding and pain in the right forearm.
By history the patient had a blunt trauma to the head and chest in the dashboard. Other previous medical history is irrelevant.

4. On examination Airway: Clear
Cervical Spine immobilization after neck examination with no major abnormality
Breathing:
RR: 20/min
Equal air entry bilateral with no adventitious sounds.
Tenderness over the sternum.
SpO2: 95% on room air.

5. Circulation:
There is no major site of bleeding, vital signs include:
HR: 100/min felt central and peripheral, equal on both sides.
Blood pressure: 100/60 mmHg.
Capillary refill time: 1.5 sec.
Temp: 37.1C
Neck veins not congested
There is wound in the forehead 5X3 cm.

6. Pupils are equal bilateral and reactive to light.
Disability
GCS 15/15
No loss of cons, no nausea or vomiting, no bleeding per orifices, no transient amnesia and no fits.
Pupils are equal bilateral and reactive to light.
Blood sugar 140 mg/dl.
Exposure
No major bleeding
No major deformity

7. Discussion on part one of the lecture

8. Types of assessment Primary Survey and resuscitation
Identification of Life threatening conditions
AcBCDE Approach
Secondary Survey
Detailed head to toe examination
Medical history
All lab and radiology investigation ordered
Management Plan

9. PURPOSE OF THE INITIAL ASSESSMENT
Identification of LIFE-THREATENING emergencies
Assess – Change - Reassess
Initiation of LIFE-SAVING measures (CPR)
Illinois EMSC

10. 5 second Round Pt is conscious or not Airway Ventilation
Signs of massive external hemorrhage
There is any deformity
Skin color and temp with feeling pulse
Illinois EMSC

11. Primary Survey Airway/ Cervical Spine Control Breathing Circulation
Disability (neurological)
Expose
Illinois EMSC

12. Assessing Airway
Is the airway:
Clear and safe?
At risk?
Obstructed?

13. AIRWAY INTERVENTIONS Jaw thrust Vs Head tilt.
Deliver Oxygen (mask with reservoir).
Use Rigid suction.
Secure airway.
Illinois EMSC

14. 5 Chest clues in the neck Wounds Distended neck veins
Tracheal position
Surgical emphysema
Laryngeal crepitus

15. CERVICAL SPINE STABILIZATION
Place hands on either side of the head cervical collar.flv
Maintain neck midline “manual in line stabilization”
Illinois EMSC

16. Breathing and ventilation
Aims
Support if inadequate
Eliminate any immediately life threatening thoracic condition …..

17. Breathing and ventilation
Inspection
Respiratory rate
Effort of breathing
Symmetry
Wounds & marks
Palpation
Tender points, equal expansion
Percussion
No abnormal note
Auscultation
All lung zones

18. BREATHING INTERVENTIONS
If breathing is absent, start ventilation using:
Simple Adjuvants (Airways)
Bag valve mask with reservoir
LMA
ETT
Illinois EMSC

19. Fatal Chest conditions?
Tension pneumothorax
Open chest trauma
Cardiac tamponade
Flail chest
Massive hemothorax
Illinois EMSC

20. CIRCULATORY ASSESSMENT
Carotid pulse (absent or present)
Capillary refill
Skin color
Skin temperature
Sites of bleeding
Illinois EMSC

21. CIRCULATORY INTERVENTIONS
If central pulse is absent, begin CPR
Apply direct pressure to open wounds
IV access (2 wide bore cannulae14/16G).
Fluids (colloids Vs crystalloids) 20ml/Kg
Peripheral Vs central line?

22. Dysfunction of the CNS Aims Rapid neurological assessment
Alert; Voice; Pain; Unresponsive
Pupils
Mini-neurological assessment
GCS score / AVPU
Lateralising signs
Blood sugar
If GCS 8 or less intubate if not already done so

24. Exposure and environment
Aims
Remove clothing to allow examination of entire patient
Care when removing tight trousers
Prevent hypothermia
Patient dignity
Remove spine board
Prevent hypothermia
Cover over
Warming devices
Room temperature
Worse if spinal injury

25. Don’t Forget The Back

26. Pause & check
Are all immediately life-threatening injuries identified?
Is all monitoring in place?
Investigations ordered?
Analgesia?
Relatives informed?
Non-essential team members disbanded?
Ensure all monitoring in place
ECG, BP, SpO2, etCO2, urine output
Tests:
Chest and pelvic x-rays
Ultrasound CT
FBC, U&Es, BS, cross-match, pregnancy test, arterial blood gases

27. The well practiced trauma team should aim to complete the primary survey in less than 10 minutes
Illinois EMSC

28. Radiology
Once the patient is stabilized the patient is sent to radiology for the survery:
Cervical spine X-ray (AP and lateral view)
Chest X- ray (Rib cage)
Pelvis X-ray
Abdomen and Pelvis U/S
CT brain is ordered if there is suspicion of head trauma
X-ray of extremities if fracture is suspected.

29. Chest X-Ray

31. Part 2 case
Patient returned form the radiology department complaining of severe chest pain and could not lay down on his back for suturing of the cut wound in the forehead
Patient received the following medication:
1500 cc of normal saline
cefoperazone 1.5 gm IV
Analgesia as Perfalgan 1gm IV followed by Pethedine 50 mg IM

32. Labs were send for urgent Hb Patients Vital signs were:
HR: 120/min
Blood pressure 85-90/50-60 mmHg.
CRT 2 sec
SpO2:92 % On Room air.
Patient still complains of severe chest pain and received another 50 mg pethedine over 100 cc Normal Saline over 30 min

33. Differential
Diagnosis

34. What is the next step

35. What Labs to order?
What other radiological investigations to ask for?
What other medications to give?

36. Chest X-Ray Mediastinal widening Double aortic knob sign
Tracheal displacement to the right
Left apical opacity
Diffuse enlargement of the aorta
Pleural effusion
Fractured first or second ribs
Pericardial effusion
Cardiac enlargement

37. CT chest

38. Aortograghy

40. Aortograghy

41. Final Diagnosis
Traumatic aortic tear

42. THORACIC TRAUMA

43. Traumatic Aortic Rupture
These are found in victims of high-speed motor vehicle crashes and falls from great heights, and 85% of these injuries are due to blunt trauma.
The majority (80-90%) of the patients die at the scene of the accident from massive blood loss. Of the patients reaching hospital alive, only 20% will survive without operation.
The mortality remains high even after surgery.

44. In cases of aortic rupture, the clinical presentation depends upon the site of injury. Patients with injury to the intrapericardial portion of the ascending aorta will usually develop a cardiac tamponade.
Extrapericardial ascending aortic injury produces a mediastinal haematoma and a haemothorax, usually on the right side

45. Rapid deceleration is believed to be responsible for damage to the aorta that most commonly occurs in the region of ligamentum arteriosum, just distal to the origin of left subclavian artery.

46. Patients may show transient hypotension, which responds well to fluid therapy and further clinical signs may be absent.
This may delay the diagnosis with catastrophic results should the aorta rupture completely. Thus a high index of suspicion should be kept in mind.

47. Aortic disruption should always be suspected in patients with profound shock and who have no other external signs of blood loss and in whom mechanical causes of shock (tension pneumothorax and pericardial tamponade) have been excluded.

48. Aortic dissection Vs ACS.
Symptoms (if the patient is conscious) may include:
Severe retrosternal pain
Pain between the scapulae
Hoarseness of voice (pressure from haematoma on the recurrent laryngeal nerve)
Dysphagia
Paraplegia or paraparesis
Aortic dissection Vs ACS.

49. The definitive investigation of choice is angiography or a CT angiogram of the aortic arch, the choice depending on local policy.
Survival in patients who have their injury repaired surgically and who have remained haemodynamically stable during the repair is 90%.

50. Minimally invasive repair using aortic stenting techniques are also being used

51. MANAGEMENT OPEN PNEUMOTHORAX
Ensure adequate airway
100% oxygen
Seal open wound
Load & Go
IV access en route
Notify Medical Direction
Courtesy of David Effron, M.D.

52. SEALING THE OPEN WOUND
Asherman chest seal is very effective

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

54. TENSION PNEUMOTHORAX

55. MANAGEMENT TENSION PNEUMOTHORAX
Ensure adequate airway
100% oxygen
Needle decompression if indicated
Load & Go
IV access en route
Notify Medical Direction

56. MCQ
Which of the following is true in regards to a traumatic aortic rupture?
A. There is a 50% survival rate
B. Immediate defibrillation is indicated
C. Usually due to deceleration injury
D. They are easily diagnosed in the pre-hospital setting

57. 3. What is the MOST likely abnormality that would be seen on chest x-ray in a patient with traumatic rupture of the aorta after blunt injury?
Obscuration of the aortic knob
Deviation of esophagus to the left
Fracture of the first or second rib
Apical cap
Superior mediastinal widening

58. 3. Male patient with intracerebral hemorrhage and intra-abdominal bleeding, the optimum blood pressure for this patient should be maintained around:
90 mmHg.
100 mmHg.
110 mmHg.
70 mmHg.

59. 4. The initial management of a poly-trauma patient should include the following order:
Conscious level, secure airway, assess circulation , control cervical spine, assist ventilation and exposure.
Secure airway, control cervical spine, assess circulation, follow up conscious level and assist ventilation and exposure.
Secure airway, control cervical spine, assist ventilation, assess circulation, follow up conscious level and exposure.
control cervical spine , secure airway, assist ventilation, assess circulation, follow up conscious level and exposure.

60. 5-Which of the following is the BEST screening test for detecting traumatic aortic injury in a stable patient? (A) Chest radiograph. (B) Computed tomography aortography. (C) Trans-thoracic echocardiography. (D) Test for unequal blood pressures in the upper extremities..

61. Recommendations
All Trauma patients should be assessed using the universal AcBCDE approach.
Management of Poly-trauma should include primary and secondary survey.
Team work is standard in management of trauma patients.
Routine investigation should be implemented as a protocol for our policy in Demerdash and ASUSH.
High index of suspicion should be kept for aortic trauma in any posttraumatic chest pain.

62. QUESTIONS?

63. THANK YOU