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Management of patients with multiple trauma . Prof. M K Alam MS; FRCS. ILO’s. Incidence of trauma Causes and types of trauma Timing and mode of death in trauma patients and its effect on trauma management. Pre-hospital care and triage Hospital care Primary survey and initial management

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ilo s
ILO’s
  • Incidence of trauma
  • Causes and types of trauma
  • Timing and mode of death in trauma patients and its effect on trauma management.
  • Pre-hospital care and triage
  • Hospital care
  • Primary survey and initial management
  • Secondary survey
  • Pathophysiology of common injuries
  • Investigations during primary and secondary survey
  • A brief outline of management of major injuries.
epidemiology
Epidemiology
  • Trauma remains the most common cause of death between the ages of 1 and 44 years.
  • Affects a disproportionate number of young people- the burden to society in terms of lost productivity, premature death, and disability is considerable.
  • A major public health issue.
arab news 16 th feb 20141
Arab News 16thFeb 2014
  • 20 deaths daily on the Kingdom's roads.
  • Last year- 707 amputations due to RTA.
  • Accidents increased by 78% in the KSA recently
  • Affecting mostly young between 18 and 22 years
  • Around 30% of those injured are permanently disabled.
  • The state has spent SR21 billion treating such patients
causes of trauma
Causes of trauma
  • RTA or MVA
  • Pedestrian trauma
  • Fall from height
  • Assault
  • Firearm injuries
  • Knife
  • Industrial accidents
  • Natural disasters
  • Explosions
types of trauma
Types of trauma
  • Blunt trauma results of an impact from blunt object
  • Penetrating trauma results from an object piercing the body
  • Assessment and diagnosis of blunt injuries are more difficult than of penetrating injuries
  • Multi-trauma- injury affecting simultaneously different organ and body system
trimodal death in trauma
Trimodal death in trauma
  • Immediate:Within seconds or minutes after injury- 50% of deaths due to injury to the aorta, heart, brainstem, or spinal cord or by acute respiratory distress.
  • Early:Within hours of injury- approximately 30% of deaths. Half of these deaths are caused by hemorrhage and the other half by central nervous system (CNS) injury. These patients can be saved by appropriate treatment (golden hour).
  • Late: peaks from days to weeks, mortality due to infection and multiple organ failure.
improvement in mortality
Improvement in mortality
  • Early deaths: Prevention and control program by legislation and behavior modification
  • Later deaths:
      • Trauma centers providing better care.
      • Better understanding of pathophysiology of multiple organ failure and brain injury
pre hospital care
Pre-hospital care
  • Delivery to the hospital for definitive care as rapidly as possible- scoop and run
  • Only critical interventions at the scene
  • Airway established, hard collar, spine board, control any external hemorrhage
  • Infusion on way to the hospital
triage
Triage
  • Definition:

Prioritizing victims into categories based on their severity of injury, likelihood of survival, and urgency of care.

  • Goals:
    • Identify high-risk injured patients who would benefit from the resources available in a trauma center.
    • Limit the excessive transport of non-severely injured patients so that the trauma center is not overwhelmed.
hospital care
Hospital care
  • ATLS approach
  • A well defined order
  • Primary survey- initial assessment and management
  • Treat the greatest threat to life
  • Immediate intervention as the threat to life is identified
  • Detailed history not essential
  • Re-evaluation of initial management
  • Secondary survey- a head to toe evaluation
primary survey
Primary survey
  • A B C D E
  • Airway & cervical spine protection
  • Breathing
  • Circulation
  • Disability (neurologic assessment)
  • Exposure and Environmental control
primary survey a team approach
Primary survey- a team approach
  • Simultaneous diagnosis and treatment by multiple providers
  • Reduces the time to assess and stabilize a multiple trauma patients
  • Team should be organized before patient arrival.
  • Leadership and unity of command are essential
primary survey one clinician
Primary survey-one clinician

Do not perform subsequent steps in the primary survey until after addressing life-threatening conditions in the earlier steps.

airway cervical spine
Airway & cervical spine
  • Verbal response: Salam! How are you?

Airway is compromised if:

  • No response- unconscious , airway obstruction
  • Noisy breathing
  • Severe facial trauma
  • Oropharyngeal bleeding or foreign body
  • Patient agitated - hypoxia
airway cervical spine1
Airway & Cervical spine
  • Adequacy of airway- completed within seconds
  • Open the front of the collar for airway manipulation
  • Maintain manual stabilization by an assistant
  • Oropharyngeal airway/ bag valve mask ventilation
  • Oxygen supplement + pulse oximetry
  • Rapid-sequence endotracheal intubation
  • Frequent reassessment for airway compromise
difficult airway
Difficult airway
  • Surgical airway when oral intubation cannot be accomplished:
    • Cricothyroidotomy –Surgical
    • Percutaneous needle technique- only temporary
    • Tracheostomy (laryngeal injury)
breathing
BREATHING

Life threatening injuries to look for:

  • Tension pneumothorax
  • Open pneumothorax (open chest wound)
  • Flail chest with underlying pulmonary contusion
  • Massive hemothorax
breathing1
BREATHING
  • Dyspnoea
  • Unilateral diminished chest expansion
  • Bruising/ abrasion
  • Distended neck vein
  • Trachea deviated to the opposite side
  • Percussion: dull - haemothorax Hyper resonant - Pneumothorax
  • Diminished/ absent breath sound
tension pneumothorax p athophysiology
Tension pneumothoraxPathophysiology
  • Collapsed lung acts as a one-way valve
  • Each inhalation- additional air accumulate in the pleural space.
  • Normal negative intrapleural pressure becomes positive, depressing the ipsilateral hemidiaphragm, pushing the mediastinal structures into the contralateral chest
  • Contralateral lung is compressed, the heart is rotated about the superior and inferior vena cava, decreasing venous return and cardiac output while distending the neck veins
tension pneumothorax clinical features treatment
Tension pneumothoraxClinical features & treatment
  • Respiratory distress
  • Tracheal deviation away from the affected side
  • Lack of or decreased breath sounds
  • Distended neck veins or systemic hypotension
  • Subcutaneous emphysema, hyper resonance
  • Treatment: x-ray confirmation not required
  • Wide bore needle in 2ndinercost. space, mid clavicular
  • Chest tube in 5thintercost. space, ant. axillary line
open pneumothorax or sucking chest wound pathophysiology
Open pneumothorax or sucking chest woundPathophysiology
  • Full-thickness loss of the chest wall: free communication between the pleural space and the atmosphere.
  • Collapse of the lung on the injured side
  • If the diameter of the injury is greater than the narrowest portion of the upper airway, air will preferentially move through the injury
  • Impair ventilation on the contralateral side
open pneumothorax management
Open pneumothoraxManagement
  • Complete occlusion of the injury may result in converting an open pneumothorax into a tension pneumothorax.
  • Initial treatment: occlusive dressing, which is taped on three sides over the wound
  • Dressing permits effective ventilation, while the untaped side allows accumulated air to escape from the pleura
  • Definitive treatment: wound closure and tube thoracostomy
flail chest with pulmonary contusion pathophysiology
Flail chest with pulmonary contusion Pathophysiology
  • Four or more ribs fractured in at least two locations
  • Paradoxical movement of free-floating segment may occasionally compromise ventilation.
  • More importantly, an underlying pulmonary contusion may compromise oxygenation or ventilation
  • Initial chest x-ray underestimates the degree of contusion.
  • The lesion evolve with time and fluid resuscitation.
flail chest with pulmonary contusion management
Flail chest with pulmonary contusionManagement
  • Respiratory failure in these patients may not be immediate
  • Frequent re-evaluation is needed.
  • Intubation and mechanical ventilation is required
massive hemothorax
Massive hemothorax
  • Accumulation of >1.5L of blood
  • Disruption of large vessel
  • Flat neck vein
  • Dullness on percussion
  • No breath sound
  • Shock
  • Management:Chest tube in 5th space, fluid resuscitation. Thoracotomy if significant bleeding continues.
circulation
Circulation
  • Assessment of cardiovascular compromise and management
  • Is the patient in shock?
  • Any external bleeding source?
  • Any internal hemorrhage?
circulation pathophysiology
CirculationPathophysiology
  • Shock is secondary to hemorrhage in most trauma patients
  • Patient can be in shock before developing hypotension
  • Hypotension- a sign of decompensation (class III )
  • 5 locations for major blood loss:

Chest

Abdomen

Pelvis and retroperitoneum

Multiple long bone fractures ( lower limb)

External hemorrhage

pathophysiology of blood loss
Pathophysiology of blood loss
  • Responses are compensatory
  • Progressive vasoconstriction- skin, muscle, viscera
  • Tachycardia to preserve cardiac output
  • Increased peripheral resistance- catecholamines
  • Venous return preserved in early stage by reduced blood volume in venous system
  • Continued bleeding- shock develops
  • Inadequate tissue perfusion, metabolic acidosis
circulation indicators of shock in trauma patients
CirculationIndicators of shock in trauma patients
  • Tachycardia*
  • Agitation
  • Tachypnea
  • Sweating
  • Cool extremities
  • Weak peripheral pulse
  • Decreased pulse pressure
  • Hypotension
  • Oliguria
circulation cardiogenic shock
CirculationCardiogenic shock
  • Tension pneumothorax- most common cause, Pericardial tamponade(penetrating trauma), Myocardial contusion
  • Beck’s triad- hypotension, distended neck vein (raised CVP >15 cm H2O), muffled heart sound
  • CVP: Hemorrhagic <5 cmH2O
  • Dysrhythmias in contusion
  • Ultrasonography : helpful in diagnosis
  • Treatment: fluid resuscitation, pericardiocentesis
circulation neurogenic shock
CirculationNeurogenic shock
  • Loss of sympathetic tone due to cord injury
  • Hypotension, warm well perfused limbs, diminished/absent motor function
  • Bradycardia
  • Management: IV fluid, vasopressor, corticosteroids
circulation septic shock
CirculationSeptic shock
  • Delayed arrival
  • Penetrating abdominal injuries
  • Early septic shock- normal circulating volume
  • Tachycardia
  • Warm skin
  • Systolic close to normal,
  • Wide pulse pressure
circulation initial management
Circulation Initial management
  • External haemorrhage- compression dressing
  • IV access- two peripheral catheters
  • ECG monitoring
  • Blood sample- typing and lab. investigations
  • Initial resuscitation:1-2L of Ringer's lactate or NS
  • Packed red blood cells if no response
  • Foley’s catheter: urine output is .5 mL/kg/hour in adult
circulation initial management1
Circulation Initial management

Search for any source of blood loss:

  • CXR, X-ray pelvis, FAST (focused abdominal sonography in trauma)
  • If fracture pelvis is found pneumatic antishock garment or a bed sheet wrapped around the pelvis may be applied
evaluation of fluid resuscitation
Evaluation of fluid resuscitation
  • BP and pulse rate
  • Urine output (0.5ml/kg/hour)
  • Mental status and skin color/temperature
  • CVP
  • Acid/base status
management decisions rapid responders
Management decisionsRapid responders
  • Hemodynamics return to normal after fluid resuscitation
  • Hemodynamics remain stable even after reducing infusion to maintenance rate.
  • Probably bleeding has stopped spontaneously
  • Continued evaluation for source of bleeding
  • May still need surgery
management decisions transient responders
Management decisionsTransient responders
  • Decompensate once fluid resuscitation is slowed down
  • There is ongoing bleeding or inadequate resuscitation
  • Increase fluid resuscitation and blood transfusion (type specific or O negative)
  • ?Surgical intervention
management decisions non responders
Management decisionsNon-responders
  • Fail to respond to fluid and blood resuscitation
  • Major blood loss (>40%) & ongoing loss
  • Immediate surgical intervention
  • ? Non-hemorrhagic shock (cardiogenic)
  • Echocardiography
  • CVP
disability neurologic evaluation
DisabilityNeurologic evaluation
  • Level of consciousness measured by the Glasgow Coma Scale (GCS)
  • If the GCS is used in intubated and paralyzed patients, record should be made
  • Pupillary response can still be assessed in a paralyzed patient
head injury severity
Head injury severity
  • Mild GCS ≥ 13
  • Moderate GCS 9- ≤ 12
  • Severe GCS ≤ 8
exposure environment control
Exposure/ Environment control
  • Completely undress the patient
  • Perform a rapid head-to-toe examination
  • Identify any injuries to the back, perineum, or other areas that are not easily seen in the supine position
  • Unexpected injuries may be discovered
  • Once assessment completed, cover the patient with blanket ( prevent cold exposure)
secondary survey
Secondary Survey
  • Only after completion of primary survey(ABCDE)
  • Life threatening injuries have been dealt
  • Normalization of vital signs
  • A head to toe evaluation
  • Detailed history and examination
  • Continuous reassessment of vital signs
  • Additional lab. & radiological tests and collecting results
  • Additional tubes, lines and monitoring devices
  • Priorities and plan definitive management of all injuries
head injury
Head injury
  • Traumatic brain injury (TBI)- the leading cause of death in trauma patients- 50% of all traumatic deaths.
  • Primary injury- the anatomic and physiologic disruption that occurs as a direct result of trauma
  • Secondary injury- extension of the primary injury, result from local swelling, increased ICP, hypoperfusion, hypoxemia, or other factors.
  • Aim- detection and treatment of primary injury and prevention of secondary injury
head injury management
Head injury- management
  • Maintain BP >90 mmHg, PaO2 >60 mmHg
  • Assess GCS and lateralizing signs- pupil and motor function
  • Pupillary asymmetry >1 mm suggests intracranial injury
  • Larger pupil is on the side of the mass lesion
  • Extremity weakness- detected by testing motor power
  • CT scan head- accurate localization of the lesion
  • Epidural or subdural hematoma causing mass effect evacuated
  • Diffuse axonal injury- maintain cerebral perfusion and prevent rise in ICP
spinal cord injuries
Spinal cord injuries
  • Intensive hospital care, long-term rehabilitation, life-long care.
  • Initial care- strict immobilization of the spine
  • Complete neurologic assessment
  • Steroid therapy must be initiated within a few hours of injury
  • Injuries above C3- are apneic, need intubation
  • between C3 and C5 – may need intubation later
  • Complete transection- poor prognosis
  • Preservation of remaining function
thoracic injuries
Thoracic injuries
  • Life-threatening :tension pneumothorax, massive hemothorax, open pneumothorax, flail chest, and cardiac tamponade
  • Rib fractures, sternal fracture, lung contusion, Injuries to trachea, bronchi, heart, diaphragm, esophagus, thoracic aorta
  • Diagnostic modalities: CXR, ultrasonography, chest CT, esophagography, esophagoscopy, bronchoscopy, and angiography
abdominal injuries
Abdominal injuries
  • 25% of all trauma victims require abdominal exploration.
  • Physical examination- inadequate to identify intra-abdominal injuries
  • Diagnostic modalities- CXR, FAST, DPL,CT & laparoscopy
  • Blunt trauma:
  • Hemodynamically stable- CT scan ,
  • Hemodynamically unstable- FAST
diagnostic peritoneal lavage dpl
Diagnostic peritoneal lavage (DPL)
  • Insert catheter below umbilicus under LA and full asepsis and saline (1L NS) infusion into peritoneum
  • Returning fluid is bloody- +ve lavage
  • Rapid and safe
  • Bloody aspirate- laparotomy
  • Do not determine origin of blood
  • Too sensitive
  • Does not evaluate retroperitoneal injury
  • Replaced by FAST and CT scan
fast focused abdominal sonography in trauma
FAST-focused abdominal sonography in trauma
  • Superseded DPL in assessment of abdominal trauma
  • 98% sensitivity for hemoperitoneum
abdominal injuries penetrating
Abdominal injuries (penetrating)
  • All gun shot injuries- urgent surgery
  • Stab (knife) injury:

Hemodynamically stable- CT scan, surgery only if intra-abdominal injuries found

Hemodynamically unstable- surgery

splenic injury
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
splenic injury non surgical management 70
Splenic injury Non-surgical management (70%)
  • Hemodynamically stable patients:
  • FAST, CT for diagnosis
  • No other intra-abdominal injury requiring operation
  • Admission to ICU for continuous monitoring
  • Serial Hb. , & repeated abdominal assessment
  • If hypotension develops - taken for surgery
splenic injury surgical management
Splenic injury Surgical management
  • Hemodynamically unstable
  • FAST: splenic injury, free fluid (hemoperitoneum)
  • Surgery- splenectomy
  • Polyvalent pneumococcal vaccine (pneumovax)
liver injury pathophysiology
Liver injury- pathophysiology
  • Susceptible to injury due to large size(1200-1600 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
liver injury
Liver injury
  • Spontaneous hemostasis- 50% of small lacerations
  • Profuse bleeding from deep hepatic lacerations- a formidable challenge
  • Mortality rate 8%- 10%, morbidity rate from 18%-30%,
  • Diagnosis: FAST in hemodynamically unstable, CT scan in hemodynamically stable
  • Management based on hemodynamic status
liver injury non operative management
Liver injuryNon-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
liver injury surgical management
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- when fail to control hemorrhage
  • Packs removed in 48 hours
pancreatic injuries
Pancreatic injuries
  • Pancreatic injury is rare
  • Caused by penetrating injury or direct blow
  • Diagnosis is difficult to make
  • CT scan, elevated serum amylase may help
  • No duct injury: simple drainage
  • Ductal injury: distal resection
bowel injuries
Bowel injuries
  • Mostly due to penetrating trauma
  • Also seen after blunt trauma
  • Features of peritonitis
  • CT scan free air in peritoneum/ contrast leak
  • Small bowel: Suture repair
  • Colon: suture repair± proximal colostomy
renal injuries
Renal injuries
  • Minor- renal contusion(85%)

Conservative management

  • Major:

Deep medullary injuries with extravasation Vascular injuries

Surgical repair

slide99

An ambulance is bringing a young man who was riding a motor bike. He was thrown from the speeding motor bike on a bending road. He was not wearing a safety helmet. His left leg appears grossly deformed.

  • The ambulance has informed ER before bringing him.
  • You are the only doctor in ER
  • What to do?
preparation before patient arrival
Preparation before patient arrival
  • Airway equipment, cervical collar, pulse oximetry, ECG monitor, oxygen
  • Laryngoscope, Needles, chest tubes, under-water seal,
  • Minor op. set, local anaesthetic,
  • IV fluids at room temp.
  • Blood sample tubes
  • Splints
  • Radiologist and technician
  • Foley catheter and urine bag
management in a hospital
Management in a hospital
  • Patient arrives in hospital
  • Patient is on a spinal board
  • Deformed left lower limb with blood stain on cloth?
  • What to do next?
assessment of airway
Assessment of airway
  • Talk to the patient

Danger signs

  • Not talking
  • Oro-facial bleeding
  • Confused
  • Agitated
  • Neck hematoma
airway management
Airway management
  • Clearing oral cavity
  • Oropharyngeal / bag valve mask
  • Chin lift / jaw thrust
  • Oral endotracheal intubation
  • Surgical methods
  • Adjuncts: oximetry, oxygen
  • Cervical collar if not applied during transport
  • Manual in-line support by an assistant
breathing2
Breathing
  • Patient continues to be dyspnoeic?
  • Oxygen saturation not improving?
  • Chest injuries to look for and manage
  • Tension pneumothorax
  • Massive hemothorax
  • Flail chest
  • Open chest wound

pO2 and respiratory rate improves

circulation1
Circulation
  • Pulse, BP,RR
  • Any external bleeding? Look at his deformed limb
  • 2 IV line, blood samples
  • RL or NS 1-2 L as bolus rapidly
  • Quick response: slow down iv to maintenance
  • Transient response: BT ?bleeding
  • No response: ?Major bleeding ? Inadequate resuss. ?non- hemorrhagic shock ( cardiogenic, spinal, septic)
hemorrhagic vs non hemorrhagic shock
Hemorrhagic vs Non-hemorrhagic shock
  • Neck vein
  • Pulse (rhythm, volume, rate)
  • Heart sound
  • ECG
  • CVP

Later :

Spinal injury

Late presentation with abdominal injury

major bleeding sources
Major bleeding sources
  • Chest: massive hemothorax
  • Abdomen: hemoperitoneum
  • Pelvis: pelvic & retroperitoneal hematoma
  • Lower limb fractures
investigations for bleeding source
Investigations for bleeding source
  • CXR*
  • FAST
  • DPL
  • CT
  • X-ray pelvis*

*X-ray c spine- the only other x-ray allowed during Primary survey

disability exposure
Disability & Exposure
  • GCS
  • Full exposure including the blood mark on his lower limb.
  • Splint the limb- if not already done during assessment for external hemorrhage
  • Cover patient with a blanket
  • Reassess ABCD
secondary survey1
Secondary survey
  • Only after completion of primary survey(ABCDE)
  • Life threatening injuries have been dealt
  • Normalization of vital signs
  • A head to toe evaluation
  • Detailed history and examination
  • Continuous reassessment of vital signs
  • Additional lab. & radiological tests and collecting results
  • Additional tubes, lines and monitoring devices
  • Priorities and plan definitive management of all injuries