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What is polytrauma Multiple traumatic injuries to a victum.

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Presentation on theme: "What is polytrauma Multiple traumatic injuries to a victum."— Presentation transcript:


2 What is polytrauma Multiple traumatic injuries to a victum.

3 Overview of ATLS

4 Types of assessment 4 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

5 Illinois EMSC5 PURPOSE OF THE INITIAL ASSESSMENT Identification of LIFE-THREATENING emergencies Assess – Change - Reassess Initiation of LIFE-SAVING measures (CPR)

6 5 second Round Illinois EMSC6 Pt is conscious or not Airway Ventilation Signs of massive external hemorrhage There is any deformity Skin color and temp with feeling pulse

7 Illinois EMSC7 Primary Survey Airway/ Cervical Spine Control Breathing Circulation Disability (neurological) Expose

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

9 Illinois EMSC9 AIRWAY INTERVENTIONS Jaw thrust Vs Head tilt. Deliver Oxygen (mask with reservoir). Use Rigid suction. Secure airway.

10 5 Chest clues in the neck Wounds Distended neck veins Tracheal position Surgical emphysema Laryngeal crepitus

11 Illinois EMSC11 CERVICAL SPINE STABILIZATION Place hands on either side of the head cervical collar.flv cervical collar.flv Maintain neck midline “manual in line stabilization”

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

13 Breathing and ventilation Inspection Respiratory rate Effort of breathing Symmetry Wounds & marks Palpation Percussion Auscultation All lung zones

14 Illinois EMSC14 BREATHING INTERVENTIONS If breathing is absent, start ventilation using: Simple Adjuvants (Airways) Bag valve mask with reservoir LMA ETT

15 Surgical Airway Cricothyroidotomy (tracheostomy) Indication Unable to intubate(sever maxillo-facial injury) Contraindication Transection of the airway

16 Fatal Chest conditions? Tension pneumothorax Open chest trauma Cardiac tamponade Flail chest Massive hemothorax Illinois EMSC16

17 Tension Pneumothorax Signs and Symptoms Chest pain, respiratory distress, tachycardia, hypotension, tracheal deviation, absent breath sounds, neck vein distention. Immediate decompression Needle thoracostomy Chest tube insertion

18 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.

19 Open pneumothorax >2/3 of the tracheal diameter 3 sided wound dressing Chest tube insertion

20 SEALING THE OPEN WOUND Asherman chest seal is very effective

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

22 Cardiac temponade Penetrating injury Becks Triad 1) Elevated central venous pressure (distended neck veins) 2) Muffled heart sounds 3) low blood pressure FAST scan /ECHO Pericardiocentesis

23 Flail Chest > 2 ribs fractured in 2 or more places usually on the same or opposite side of the chest. Paradoxical chest wall movement. Adequate ventilation/ inadequate ventilation Chest tube insertion

24 Massive heamothorax >1500 cc or 1/3 of the blood volume in the lung cavity I/V resuscitation Chest tube insertion Thoracotomy > 1500 cc immediately 200 cc/h for 2-4 hours

25 Illinois EMSC25 CIRCULATORY ASSESSMENT Carotid pulse (absent or present) Capillary refill Skin color Skin temperature Sites of bleeding

26 26 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?

27 Hemorrhagic Shock Most common cause of shock in trauma External vs Internal hemorrhag Blood volume = 7% of BW Rx : Volume replacement Shock classification

28 Classification Type % blood loss - p<100 - BP Normal - PP Normal - RR Urine output > 30cc/h - Mental status : Slightly anxious

29 Classification Type % blood loss - p>100 - BP Normal - PP Decreased - RR Urine output 20-30cc/h - Mental status : Mildly anxious

30 Classification Type % blood loss - p>120 - BP Decreased - PP Decreased - RR Urine output > 5-15cc/h - Mental status : Confused

31 Classification Type 4 - >40% blood loss - p>140 - BP Decreased - PP Decreased - RR >35 - Urine output Nil - Mental status : Confused/ Lerthargic

32 Fluid Replacement Class 1-2 : Crystalloid Class 3-4 : Crystalloid, Blood Initial Fluid Therapy - 1 to 2 L for adult - 20cc/kg for children “3-for-1 Rule” - 1cc blood loss = 3 cc crystalloid replacement

33 Response to Fluid resuscitation Rapid response - < 20% blood loss - Cross match and surgical consult Transient response % blood loss - Ongoing blood loss - Blood transfusion, Surgical Intervention No response - Immediate operative intervention

34 Neurogenic Shock Isolated intracranial injuries do not cause shock. Loss of sympathetic tone: Spinal cord injury Hypotension without tachycardia Initially treated as Hypovolemia DDx for non responder

35 Dysfunction of the CNS Aims Rapid neurological assessment Alert; Voice; Pain; Unresponsive Pupils Mini-neurological assessment GCS score / AVPU Pupils Lateralising signs Blood sugar

36 Factors affecting level of consciousness Oxygenation Ventilation Perfusion Hypoglycemia Alcohol Trauma

37 Head injury severity GCS Mild Moderate 9-12 Severe <8

38 Head injury Types Skull Fractures Intracranial Bleed - Epidural Hematoma - Subdural hematoma - Intracerebral Bleed - Sub arrachnoid hemorrhage - Diffuse brain injury

39 Epidural hematoma

40 Subdural Hematoma

41 Intracerebral Bleed

42 42


44 Management Mild Hi(GCS 13-15) - Neuro-observation - CT scan if LOC >5 mins Amnesia Severe headache Focal neurological deficit Moderate (GCS 9-13) - CT brain - Admit and observe neurosigns/ FU CT in hrs

45 Severe head injury Prompt diagnosis & treatment Do not delay patient’s transfer to obtain CT scan!!! Inform the Neurosurgery team and Neurology team on call as required. Intubate if indicted by the ABG’s and clinical signs. Transfer patient to OR or ICU ASAP.

46 Exposure and environment Aims Remove clothing to allow examination of entire patient Care when removing tight trousers Prevent hypothermia Patient dignity Remove spine board

47 Don’t Forget The Back

48 Pause & check Are all immediately life- threatening injuries identified? Is all monitoring in place? Investigations ordered? Analgesia? Relatives informed? Non-essential team members disbanded?

49 The well practiced trauma team should aim to complete the primary survey in less than 10 minutes Illinois EMSC49

50 Adjuncts Once the patient is stabilized the patient is sent to radiology for the survey: 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.

51 Don’t forget medical aspects of trauma Judicious fluid management Adequate and appropriate antibiotic coverage. Proper pain management. Continued vitals monitoring.

52 Secondary Survey Not to begin until primary survey is complete History (AMPLE) - Allergies - Medications - Past illnesses/ Pregnanacy - Last meal - Events Head-to-toe examination GCS X-rays Specialized diagnostic tests (CT,MRI,Endoscopy)

53 Abdominal trauma Mechanism of injury - Blunt - Penetrating History and Physical examination - inspection, palpation, percussion and auscultation - Evaluation of penetrating wound - Pelvic stability - Penile, perineal and gluetal examination - vaginal and rectal examination

54 Diagnostic Studies DPL: diagnostic peritoneal lavage FAST CT scan Abdomen/Pelvis Urethrography, Cystography MRI/MRA

55 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 patient. High index of suspicion should be kept for aortic trauma in any posttraumatic chest pain.



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