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Approach for poly-trauma patient

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Presentation on theme: "Approach for poly-trauma patient"— Presentation transcript:

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

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

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

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

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

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


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

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


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.



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