Presentation on theme: "Approach for poly-trauma patient"— Presentation transcript:
1Approach for poly-trauma patient Dr. Hany VictorLecturer of Anesthesia and ICUETC Instructor
2Objectives Case presentation on poly-trauma patient. Discussion on the caseApproach to poly-trauma patientRecommendationMCQ
3CaseMale 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.
4On examination Airway: Clear Cervical Spine immobilization after neck examination with no major abnormalityBreathing:RR: 20/minEqual air entry bilateral with no adventitious sounds.Tenderness over the sternum.SpO2: 95% on room air.
5Circulation: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: 37.1CNeck veins not congestedThere is wound in the forehead 5X3 cm.
6Pupils are equal bilateral and reactive to light. DisabilityGCS 15/15No 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.ExposureNo major bleedingNo major deformity
8Types of assessment Primary Survey and resuscitation Identification of Life threatening conditionsAcBCDE ApproachSecondary SurveyDetailed head to toe examinationMedical historyAll lab and radiology investigation orderedManagement Plan
9PURPOSE OF THE INITIAL ASSESSMENT Identification of LIFE-THREATENING emergenciesAssess – Change - ReassessInitiation of LIFE-SAVING measures (CPR)Illinois EMSC
105 second Round Pt is conscious or not Airway Ventilation Signs of massive external hemorrhageThere is any deformitySkin color and temp with feeling pulseIllinois EMSC
20CIRCULATORY ASSESSMENT Carotid pulse (absent or present)Capillary refillSkin colorSkin temperatureSites of bleedingIllinois EMSC
21CIRCULATORY INTERVENTIONS If central pulse is absent, begin CPRApply direct pressure to open woundsIV access (2 wide bore cannulae14/16G).Fluids (colloids Vs crystalloids) 20ml/KgPeripheral Vs central line?
22Dysfunction of the CNS Aims Rapid neurological assessment Alert; Voice; Pain; UnresponsivePupilsMini-neurological assessmentGCS score / AVPULateralising signsBlood sugarIf GCS 8 or less intubate if not already done so
26Pause & checkAre 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 placeECG, BP, SpO2, etCO2, urine outputTests:Chest and pelvic x-raysUltrasoundCTFBC, U&Es, BS, cross-match, pregnancy test, arterial blood gases
27The well practiced trauma team should aim to complete the primary survey in less than 10 minutes Illinois EMSC
28RadiologyOnce 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-rayAbdomen and Pelvis U/SCT brain is ordered if there is suspicion of head traumaX-ray of extremities if fracture is suspected.
31Part 2 casePatient 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 foreheadPatient received the following medication:1500 cc of normal salinecefoperazone 1.5 gm IVAnalgesia as Perfalgan 1gm IV followed by Pethedine 50 mg IM
32Labs were send for urgent Hb Patients Vital signs were: HR: 120/minBlood pressure 85-90/50-60 mmHg.CRT 2 secSpO2:92 % On Room air.Patient still complains of severe chest pain and received another 50 mg pethedine over 100 cc Normal Saline over 30 min
35What Labs to order?What other radiological investigations to ask for?What other medications to give?
36Chest X-Ray Mediastinal widening Double aortic knob sign Tracheal displacement to the rightLeft apical opacityDiffuse enlargement of the aortaPleural effusionFractured first or second ribsPericardial effusionCardiac enlargement
43Traumatic 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.
44In 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
45Rapid 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.
46Patients 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.
47Aortic 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.
48Aortic dissection Vs ACS. Symptoms (if the patient is conscious) may include:Severe retrosternal painPain between the scapulaeHoarseness of voice (pressure from haematoma on the recurrent laryngeal nerve)DysphagiaParaplegia or paraparesisAortic dissection Vs ACS.
49The 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%.
50Minimally invasive repair using aortic stenting techniques are also being used
51MANAGEMENT OPEN PNEUMOTHORAX Ensure adequate airway100% oxygenSeal open woundLoad & GoIV access en routeNotify Medical DirectionCourtesy of David Effron, M.D.
52SEALING THE OPEN WOUNDAsherman chest seal is very effective
53SEALING THE OPEN WOUNDYou can use impervious material taped on three sides
55MANAGEMENT TENSION PNEUMOTHORAX Ensure adequate airway100% oxygenNeedle decompression if indicatedLoad & GoIV access en routeNotify Medical Direction
56MCQWhich of the following is true in regards to a traumatic aortic rupture?A. There is a 50% survival rateB. Immediate defibrillation is indicatedC. Usually due to deceleration injuryD. They are easily diagnosed in the pre-hospital setting
573. 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 knobDeviation of esophagus to the leftFracture of the first or second ribApical capSuperior mediastinal widening
583. 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.
594. 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.
605-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..
61RecommendationsAll 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.