1. Case scenario- Multiple trauma
M K Alam

2. Case scenario 1
A 20 year old man was brought to ED of a small hospital. His small car skidded and hit a lamp post.

3. Report from ambulance man
Not wearing seat belt
Front wind screen was shattered
BP 90/60 mmHg
Pulse 112/ min
RR 32/ min
Management: Oral airway, cervical collar, O₂, iv fluid, spinal board

4. Pre-hospital management
Oral airway
Cervical collar
IV crystalloid infusion O₂
Spinal board

5. Vital signs on arrival to ED
BP 90/66 mmHg
Pulse 116/ min
RR 34/ min
Temperature 36.8° C
What to do?

6. A Unresponsive to your questions. Bleeding from facial lacerations
What to do?

7. A- Airway Clear airway by suctioning Unstable jaw Oxygen Open collar
Distended neck vein
Orotracheal intubation
Surgical cricothyroidotomy

8. Slight improvement in respiration.
What to do?

9. B- Breathing Right chest: Diminished movement on
Soft tissue crepitation
Hyper resonant
Diminished breath sound
Normal heart sound

10. ? Diagnosis
Tension pneumothorax
Management
Needle thoracocenteasis
ICT
Improvement in RR (22/ min)
BP - 98/ 66 mm Hg, pulse 112/ min.
What next?
What other life threatening injuries?

11. C- Circulation
Why hypotension?
?Haemorrhage
?Cardiogenic
?Neurogenic

12. C- Circulation 2nd IV line started (1st iv line – pre-hospital)
2L RL- rapid infusion
Pulse oximetry, ECG
? Foley catheter (?PR exam)- clear urine
Facial laceration bleeding- minimal
Abdomen slightly distended, pelvis stable
Limbs- no swelling, deformity or laceration
BP – 100/ 70 mmHg, Pulse 98/ min.
NG tube (? Which route)
FAST

13. FAST- Focused abdominal sonography in trauma
Rapid & accurate.
Sensitivity up to 99%.
Detects small amount (100 ml) of blood.
Four views: 1.Pericardiac 2.Perihepatic Perisplenic 4.Pelvic
Helpful in management of unstable patients.

14. FAST

15. FAST
Free fluid in abdomen
Multiple liver laceration
Management ?

16. D- Disability
What to do?

17. Glasgow Coma Scale (GCS), Total = 15
Eye response
Vocal response
Motor response
Spontaneous 4
Oriented
Obeys commands 6
To voice
Confused
Purposeful movement to pain 5
To pain
Inappropriate words 3
Withdraw from pain 4
None
Incomprehensible words 2
Flexion to pain
***
None
Extension to pain
None

18. D- Disability
E2, M4, V1
Pupil- R= 4 mm, L= 5.5mm, both reacting to light
>1 mm suggests intracranial injury
Neurosurgery consultation

19. E- Exposure/ environment control
What to do?

20. E- Exposure/ environment control
Full exposure
Areas missed?
Protect from hypothermia.

21. Preparation for Surgery
?Priority
Consent
Blood
Skin preparation
Laparotomy:
? Incision
Intraoperative: Suture liver laceration, perihepatic packing

22. Liver injury Spontaneous hemostasis- 50% of small lacerations.
Profuse bleeding from deep hepatic lacerations.
Mortality : 8%- 10% Morbidity : 18%-30%.
Diagnosis: Hemodynamically unstable- FAST Hemodynamically stable- FAST, CT scan
Management based on hemodynamic status

23. Liver injury- pathophysiology
Susceptible to injury due to large size( g)
Covered by bony thoracic cage
Injury frequency - only 2nd after spleen( personal series)
Highly vascular- only 4% of body weight but 28% of total body blood flow
Double blood supply- portal vein & hepatic artery
Draining hepatic veins- short and thin walled

24. Liver injury- CT scan

25. Liver injury- Non-operative management
Hemodynamically stable. patients
CT scan.
No other indications for abdominal exploration.
ICU admission for close observation.
Serial hemoglobin estimation.
Transfusion requirements of <2 units of blood.
Surgery- if become unstable.

26. Liver injury-Surgical management
Principles of surgical management: control of bleeding, removal of devitalized tissue, and adequate drainage.
Bleeding vessels & biliary radicles are individually ligated.
Pringle’s maneuver.
Perihepatic packing- fail to control bleeding.
Packs removed in 48 hours.

30. Abdominal injuries
25% of all trauma victims require abdominal exploration.
PE: inadequate to identify intra-abdominal injuries
Diagnostic modalities- CXR, FAST, DPL,CT & laparoscopy
Blunt trauma:
Hemodynamically stable- FAST , CT scan
Hemodynamically unstable- FAST

31. Diagnostic peritoneal lavage (DPL)
Insert catheter below umbilicus under LA.
Bloody aspirate- laparotomy.
1L NS infusion into peritoneum.
Returning fluid is bloody- positive lavage.
Rapid and safe
Do not determine origin of blood
Too sensitive
Does not evaluate retroperitoneal injury
Replaced by FAST and CT scan

32. Diagnostic peritoneal lavage (DPL)

33. Splenic injury
Most frequently injured in blunt trauma (personal series)
History of injury to the left side of the chest, flank, or left upper part of the abdomen
Bruising, pain tenderness- lower chest and upper abdomen on left side
Diagnosis- CT in hemodynamically stable patients FAST or exploratory laparotomy in an unstable patients

34. Splenic injury (CT scan)

35. Splenic injury-Non-surgical management (70%)
Hemodynamically stable.
FAST, CT scan.
No other intra-abdominal injury requiring operation
ICU admission for continuous monitoring.
Serial hemoglobin.
Repeated abdominal assessment.
If hypotension develops - for surgery.

36. Splenic injury-Surgical management
Hemodynamically unstable.
FAST: splenic injury, free fluid (hemoperitoneum).
Surgery- splenectomy .
Polyvalent pneumococcal vaccine (pneumovax).

37. Pancreatic injuries Uncommon. Penetrating injury or direct blow.
Diagnosis: difficult
CT scan, elevated serum amylase may help
No duct injury: simple drainage
Ductal injury: distal resection

39. Bowel injuries Mostly- penetrating trauma.
Less common after blunt trauma.
Features of peritonitis.
CT scan free air in peritoneum/ contrast leak.
Small bowel: Suture repair
Colon: Suture repair ± proximal colostomy

40. Bowel injuries CT: contrast leak (C) & free air Intraoperative

41. Renal injuries Minor- renal contusion (85%) Conservative management
Major:
Deep medullary injuries with extravasation Vascular injuries
Surgical repair

42. Case scenario- 2 A young male was stabbed in a car park after a dispute over parking space
ABCDE: Fully conscious, hemodynamically stable, well oriented of time and place
Abdomen:
2 cm wound just above the umbilicus. Abdomen moving well with respiration.
No active bleeding from the wound.
Non tender
Bowel sound present

43. Penetrating Abdominal injuries
Gun shot injuries- urgent surgery
Stab (knife) injury:
Hemodynamically stable- wound exploration under LA, CT scan, Surgery- if intra-abdominal injuries found.
Hemodynamically unstable- surgery

44. Thank you!