Presentation on theme: "Dr. Hany Victor Lecturer of Anesthesia and ICU ETC Instructor."— Presentation transcript:
Dr. Hany Victor Lecturer of Anesthesia and ICU ETC Instructor
Objectives Case presentation on poly-trauma patient. Discussion on the case Approach to poly-trauma patient Recommendation MCQ
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.
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.
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.
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
Discussion on part one of the lecture
Types of assessment 8 1.Primary Survey and resuscitation Identification of Life threatening conditions AcBCDE Approach 2.Secondary Survey Detailed head to toe examination Medical history All lab and radiology investigation ordered Management Plan
Illinois EMSC9 PURPOSE OF THE INITIAL ASSESSMENT Identification of LIFE-THREATENING emergencies Assess – Change - Reassess Initiation of LIFE-SAVING measures (CPR)
5 second Round Illinois EMSC10 Pt is conscious or not Airway Ventilation Signs of massive external hemorrhage There is any deformity Skin color and temp with feeling pulse
Illinois EMSC20 CIRCULATORY ASSESSMENT Carotid pulse (absent or present) Capillary refill Skin color Skin temperature Sites of bleeding
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?
Exposure and environment Aims Remove clothing to allow examination of entire patient Care when removing tight trousers Prevent hypothermia Patient dignity Remove spine board
Don’t Forget The Back
Pause & check Are all immediately life- threatening injuries identified? Is all monitoring in place? Investigations ordered? Analgesia? Relatives informed? Non-essential team members disbanded?
The well practiced trauma team should aim to complete the primary survey in less than 10 minutes Illinois EMSC27
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.
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
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
What Labs to order? What other radiological investigations to ask for? What other medications to give?
Chest X-Ray Double aortic knob sign Diffuse enlargement of the aorta Tracheal displacement to the right Pleural effusion Pericardial effusion Cardiac enlargement Left apical opacity Fractured first or second ribs Mediastinal widening
Final Diagnosis Traumatic aortic tear
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.
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
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.
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.
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.
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.
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%.
Minimally invasive repair using aortic stenting techniques are also being used
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.
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 if indicated Load & Go IV access en route Notify Medical Direction
MCQ 1. 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
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? (A) Obscuration of the aortic knob (B) Deviation of esophagus to the left (C) Fracture of the first or second rib (D) Apical cap (E) Superior mediastinal widening
3. Male patient with intracerebral hemorrhage and intra-abdominal bleeding, the optimum blood pressure for this patient should be maintained around: A. 90 mmHg. B. 100 mmHg. C. 110 mmHg. D. 70 mmHg.
4. The initial management of a poly-trauma patient should include the following order: A. Conscious level, secure airway, assess circulation, control cervical spine, assist ventilation and exposure. B. Secure airway, control cervical spine, assess circulation, follow up conscious level and assist ventilation and exposure. C. Secure airway, control cervical spine, assist ventilation, assess circulation, follow up conscious level and exposure. D. control cervical spine, secure airway, assist ventilation, assess circulation, follow up conscious level and exposure.
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..
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.