1. Management Of Multiply Injured Patients
By:
Dr. Zuhair Al-Samarrae
FRCS, FICS, CABS, DS, MBCHB

2. TRAUMA DEATHS SINCE MIDNIGHT
Trauma claims the life of millions every year.
Mostly it affects young age group-the productive section of society.
Visit Trauma.org and look at the instantly changing no.of mortality due to trauma.
TIME NOW
                 
TRAUMA DEATHS SINCE MIDNIGHT
                   

3. TIME OF ESSENCE What are areas where time is wasted?
Trimodal death and the Golden Hour
3 peaks of death
1st peak-seconds to minutes after injury-due to brain lacerations,rupture aorta….
2nd peak minutes to hours after injury-the peak of avoidable death-the golden Hour
3rd peak in ICU-due to sepsis, MOD…..
WHERE DO U PUT YOUR MONEY?

4. Time of essence Yes exactly It is in the Golden Hour
So again where is waste of time usuallly occur?
1.in the field: Scoop and run
– not stay and play
2.in hospital: be prepared
mobilize Trauma Team

5. prioritization Triaging according to :
Salvagability: Donot waste time on unsalvagable cases
Severity of injury(ABCDE): Donot waste time on <life threatening injuries

6. Spicy Pizza Ensure your safety and yor team
Triage multiple casualities
Prioritize (ABCDE)&manage accordingly
Notify the hospital
Scoop and run

7. Spicy pizza in hospital
Do Primary Survey-minutes only
What is primary survey? ABCDE
Talk to the victim:a verbal response means
a patent airway and reasonable breathing.
If no verbal reponse then
The Pizza Indian spicy&v. hot

8. ABCDE Airway and C–spine immobilization Breathing Circulation
Disability
Exposure / Environment control

9. ABCDE Open the airway: chin lift& jaw thrust No head tilt
No hyperextension
No hyperflexion
No rotation
But maintain on-line immobilization
May need adjuncts

10. airway Oro&nasopharyngeal airway Suction Removal of denture ,FB…
Ambu-bag
Endotracheal intubation, LMA
Cricothyrotomy
C-spine immobilization
In short: maintain the airway

11. Breathing 4 conditions need to be recognized-treated
Tension pneumothorax
Open pneumothrax
Flial chest
Massive hemothorax
The good news is---
u need 2 tubes&1 needle and mask
Most life-threatening thoracic injuries can be treated by airway control, needle/chest tube insertion

12. Thoracic injuries Inspect---close an open pneumoth.
Palpate –flial chest: may need intubation?
Percuss& auscultate
needle for tension pneumoth ---tube for massive hemothorax +?
Blood & R/L solution.
Again u need 2 tubes,needle,and mask

13. Circulation -SHOCK Bleeding is the predominant cause of death.
Shock recognition:
pulse, skin color , level of conciousness.
Pulse : rate. Volume and regularity.
Bp -----late
Anatomical vs physiological derangement
These changes occur with bleeding anywhere—do I need to know the exact anatomical source?
Not really ….early management is the same.

14. Hemorragic shock-management
Support circulation and stop bleeding.
Support circulation: 2 wide bore cannula
2L warmed R/L , blood
Avoid hypothermia---risk of coagulopathy.
Stop bleeding:
stop external bleeding by direct pressure
How about torniquet ?
Only in bleeding amputated limb
Splint fracture e.g pelvic fracture

15. TRANSIENT RESPONSE---WHY?
Ongoing bleed….or may be ..???
Other causes of shock-- obstructive shock
Obstructive e.g tension pneumothorax & tamponade (treated by pericardiocentesis)
Keep an eye open to other possibilities?
Neurogenic shock: IVF + - vasopressors.
Periodic re-evaluation esp indeterioration

16. D - Disability GCS or AVPU GCS 3-15: 3 worst, and 15 best
What can cause abnormal GCS?
Of course brain injury, but what else?
Hypotension and hypoxia.
Any deterioration of GCS is due to brain injury----check pulse-ox & vitals 1st .
Always assume spinal injury , so immobilize spines--- cervical collar & backboard.

17. E ----Exposure & Environment control
Exposure is nessary for proper assessment, and to avoid missing injuries
Avoid unnecessary exposure
Warmed IVF
Warm blankets
Raise room temperature.
Any relation between E & C ?

18. Adjuncts to primary survey
X-ray chest & pelvis - + C-spine
Pulse-ox
ECG monitoring
NGT.
Urinary catheter.

19. END OF PRIMARY SURVEY WHAT NOW?
Consider transfer( remember time) …next…?
Secondary survey: head- toe examination
Re-evaluate and re-evaluate…
Re-evaluate ….
Re-evaluate…

20. summary Time of essssssence Triage according to salvagability
Prioritize according to ABCDE
Early Recognition,Early intervention,Early transfer-scoop and run

21. Almond Board of California
Remember
Never forget your ABC…what is ABC?
Almond Board of California