APPROACH & MANAGEMENT OF
POLYTRAUMA
Dr.K.R.Dharmendra.,
M.S[Gen.Surg].,D.N.B[Gen.Surg].,
AL HAYAT INTERNATIONAL HOSPIT...
OUTLINE
 Concepts of trauma care
 Principles of trauma management
 ATLS Philosophy
 Damage control surgery
 Futu...
EPIDEMIOLOGY
 Trauma—commonest cause of
death between 1-40
 By 2020, injuries—third leading
cause of death
Definition of Polytrauma
 2 or more body regions with SIRS
SIRS
 2 out of 4 signs
Tachycardia >90 beats/min
Tachypnoea >20 breaths/min
Pyrexia >38 c[or hypothermia <36 c]
...
SEPSIS
SIRS with a proven infective
source
MODS
Severe Sepsis
CVS
RS
Kidney
Liver
Coagulation
METABOLIC RESPONSE TO
TRAUMA
TWO PHASES
EBB PHASE
Role: conserve volume & energy
for recovery & repair
FLOW PHASE...
EBB PHASE
 Lasts for 24-48 hrs
 Characterised by
 Hypovolaemia
 Decreased BMR
 Reduced cardiac output
 Hypothe...
FLOW PHASE
Corresponds to SIRS
Tissue oedema
Increased BMR
Increased cardiac output
Leucocytosis, Raised body te...
METABOLIC RESPONSE TO TRAUMA
PHARMACOLOGICAL
IMMUNOMODULATION
IMMUNO NUTRITION
IMMUNO
SUPPRESSION
• Epidural anaesthesia
• Statins
• B blockers
• Tranexamic acid
GRADES OF HAEMORRHAGE
REVISED TRAUMA SCORE
“WELL BEGUN IS HALF
DONE”
• Initial assessment & management
is critical in decreasing morbidity
& mortality
• Aids re...
THE GOLDEN HOUR
TRIMODAL DEATH
DISTRIBUTION
TRIMODAL DEATH
DISTRIBUTION
PRINCIPLES OF TRAUMA
MANAGEMENT
• Organised team approach
• Assumption of most serious injury
• Treatment before diagn...
TRIAGE
• In French, triage
means “to sort”
• Goals:
• To identify the high
risk injured patients
• To channelise the...
3 PHASES OF
TRIAGE
• Pre hospital Triage
• At the scene of trauma
• On arrival at hospital
MULTIPLE CASUALTIES
• The number &
severity <
Facility of the
center
• Priority is for
life threatening
injuries
MASS CASUALTIES
• The number &
severity >
Facility of the
centre
• Priority is for
best chance of
survival, least
...
COMMUNICATION
• Co ordination between pre
hospital & hospital care
• Timely preparation & mobilization
of trauma team ...
HAND OVER
• Ambulance driver to Trauma
team leader verbally
MIST
• Mechanism of Injury
• Injuries suspected
• Vital ...
TRAUMA TEAM
• For better triage & care
• Registrars from
ED
ICU
Surgery
Radiology
Anaesthesiology
• Theatre staff ...
ROLES SPECIFIED
• Team Leader—Registrar from ED or ICU
Airway Doctor
• Plans interventions & treatment in
consultation...
ATLS PHILOSOPHY
• Primary Survey & Resuscitation
• Secondary Survey
• Definitive Care
PRIMARY
SURVEY
PRIMARY SURVEY
• A—Airway Maintenance &
Cervical spine protection
• B—Breathing & Ventilation
• C--- Circulation & Hae...
C-SPINE PROTECTION
Assume a cervical spine injury
in any patient with multisystem
trauma, especially with an
altered l...
PHILADELPHIA COLLAR
• 35
Airway Management
Aims
• When is the airway potentially
threatened?
• When is the airway compromised?
• How do you tr...
Predisposing Conditions
• Coma
• Aspiration
• Maxillofacial trauma
• Neck injury
• Haematoma
• Laryngeal injury
• T...
Signs of Airway Obstruction :
"Look"
• Agitation
• Poor air movement
• Rib retraction
• Deformity
• Foreign material
Signs of Airway Obstruction :
"Listen"
• Speech? "How are you?"
Hoarseness
• Noisy breathing
• Gurgle
• Stridor
Signs of Airway Obstruction :
"Feel"
• Fracture crepitus
• Airway structures in neck
• Tracheal deviation
• Haematoma
AIRWAY RESUSCITATION
• Suction
• Chin lift
• Jaw Thrust
• Oral airway
• Definitive Airway
• POLY5-34
CHIN LIFT
JAW THRUST
When do you intubate the patient?
• This is the definitive airway
• Brain injury with GCS <8
• Severe multi system inju...
Cricothyroidotomy
INDICATIONS
• Trauma causing oral, pharyngeal
or nasal haemorrhage
• Foreign body obstruction
• Max...
Technical considerations
• No surgical Cricothyroidotomy
below 12 years
• A permanent tracheostomy within
24 hrs
• Mo...
NEEDLE CRICOTHYROIDOTOMY
COMPLICATIONS
EARLY
• Bleeding
• False passage
• Subcutaneous emphysema
• Oesophageal perforation
• Vocal cord injur...
LATE
• Infection
• Glottic & Subglottic stenosis
• Tracheo oesophageal fistula
BREATHING & VENTILATION
Abnormal Breathing : Look
• Cyanosis
• Decline in mental state
• Chest asymmetry
• Tachypnoea...
Abnormal Breathing : Listen
• I can't breathe!
• Stridor, wheezing
• Decreased breath sounds
Abnormal Breathing : Feel
• Surgical emphysema
• Chest tenderness
• Trachea deviated
• Percussion & Auscultation
DEADLY DOZEN THREATS FROM
CHEST INJURY
Immediately Life Threatening
• Airway Obstruction
• Tension Pneumothorax
• Per...
Potentially Life Threatening
• Aortic Injuries
• Tracheo bronchial Injuries
• Myocardial Contusion
• Rupture of Diaphr...
SEALING OF OPEN WOUND
Tension Pneumothorax
• Not a radiological diagnosis; only
clinical
• Put a needle in 2nd ICS in MCL
• Later ICD at 5th...
TENSION PNEUMOTHORAX
HAEMOTHORAX
• ICD
INDICATIONS OF THORACOTOMY
• Initial 1500 ml
• 200 ml for 3 consecutive hours
FLIAL CHEST
• Rib fractured at 2
different places
• Paradoxical chest
movements
• Underlying lung
contusion
• Posit...
CIRCULATION & HAEMORRHAGE
CONTROL
• Surgical Registrar & procedure
nurse apply pressure bandage to
open wounds
Signs:...
Is the heart beating?
• Is there serious external
bleeding?
• Does patient have radial pulse?
• Absent radial = systol...
Is patient perfusing?
• Cool, pale, moist skin
• Capillary refill > 2 sec
• Restlessness, anxiety,
combativeness
If i...
THE STRATEGY
• Primary Haemorrhage Control and
timely surgical intervention rather
than Overaggressive Fluid
Resuscita...
THE PROCEDURES
• IV access by procedure doctor
• 2 wide bore cannula - 14 G or 16 G
• Scalp bleeding—running locked
su...
CAUSES OF MAJOR BLEEDING
MAJOR BLEEDING -THE BIG FIVE
• EXTERNAL
• THORACIC
• PELVIC
• LONG BONES
• ABDOMEN
FLUID THERAPY
• Crystalloid fluid is preferred
• Class 3 &4 shock—colloid
fluid advised
• Bolus of 1 litre of RL given
3 RESPONDERS
• Rapid Response
Be careful, these patients may still
require surgery and may become "unstable"
again!
•...
Investigations for tissue perfusion
Transfusion Guidelines
Transfusion Guidelines
• HCT < 21
• Lesser HB trigger in
Asymptomatic patients
• Higher HB trigger in severe CV
disea...
Why RL is preferred over NS
• RL gives a hypercoagulable state
• NS causes hyperchloremic acidosis
• Significant differ...
METABOLIC ACIDOSIS
• Decreases Cardiac contractility
• Decreases effectiveness of circulating
catecholamines
• Inhibit...
DISABILITY & NEUROLOGICAL
EXAMINATION
• Level of Consciousness = Best
brain perfusion sign
• Use AVPU initially
• Che...
Brief Neurologic Examination
• A–Alert
• V –Responds to Vocal stimuli
• P–Responds to Painful stimuli
• U–Unresponsive...
Decreased LOC
• Brain injury
• Hypoxia
• Hypoglycemia
• Shock
• Never think drugs, alcohol, or
personality first
GCS
EEYYEE OOPPEENNIINNGG VVEERRBBAALL MMOOTTOORR
SSppoonnttaanneeoouuss 44 OOrriieenntteedd 55 OObbeeyyss 66
VVeerrbba...
DISABILITY INTERVENTIONS
• Spinal cord injury
–High dose steroids if within 8 hours
• ICPmonitor-Neurosurgical consulta...
Exposure&Environmental protection
• Complete disrobing of patient
• Logroll to inspect back
• Rectal temperature
• War...
Always Inspect the Back
PAUSE & CHECK
• Are all immediately life-threatening
injuries
identified?
• Is all monitoring in place?
• Investigati...
The well practiced
trauma team
should aim to
complete the
primary survey in
less than 10
minutes
Adjuncts to Primary Survey
• ECG monitoring
• Urinary and Gastric Catheters
• Monitoring
• X-rays and Diagnostics Stud...
Monitoring
1. Ventilatory rate and ABG
• Monitor the adequacy of respiration
• Confirm the ETT location
2. Pulse oxime...
X-rays and Diagnostics Studies
• Chest x-ray AP
• Pelvis AP
• Lateral C-spine
• DPL or FAST
• Films can be taken in r...
INDICATIONS FOR ICU
ADMISSION
Requirement for:
• Airway protection and mechanical
ventilation
• Cardiovascular resusc...
SECONDARY
SURVEY
SECONDARY SURVEY
• Does not begin until the primary
survey (ABCDEs) is completed
• Complete history
• Head-to-toe eval...
HISTORY
A - Allergy
M- current Medication
P- Past illness and operation
L- Last meal
E- Event and Environment
relate...
A Complete “Head to Toe’
examination
• HEENT: scalp, eyes, ears, face, throat
• Neck: distended neck veins, trachea mid...
LOG ROLLING
• 4 Persons required
• 1 - Spinal inline traction
[anaesthesiologist]
• 2 -Torso
• 3- Pelvis & Lower limb...
EXAMINATION OF BACK
• Examine entire spine
• Any penetrating injury or exit
wound
• Appropriate Dressing
• Palpation ...
SECONDARY SURVEY
‘Tubes and fingers in
every orifice’
Adjuncts to the Secondary Survey
• Further investigation for specific
injuries after stabilising the patient
• x-ray sp...
RE-EVALUATION
• Continuous monitoring of vital signs, Hct
• urinary output: adult keep > 0.5 mL/kg/hr
children keep > 1...
DPL
INDICATIONS FOR DPL
• Equivocal abdominal sign
• Unexplained hypotension
• Impaired mental status
• Paraplegia or spin...
CONTRAINDICATIONS FOR DPL
Absolute contraindication
• existing indication for explore
laparotomy
Relative contraindica...
CRITERIA FOR POSITIVE DPL
> 10 ml of gross blood in blunt trauma
• RBC count >100,000 /mm3 for blunt
trauma
• RBC coun...
DPL
DPL
Advantages
• Fast
• Sensitive
• Can be performed while resuscitation
ongoing
Disadvantages
• Invasive
• Learni...
FAST
FAST
• Detect intra abdominal fluid
• Rapid, noninvasive, accurate,
inexpensive, can repeat frequently
• Indications s...
FAST
ADVANTAGES OF FAST
• Fast
• Noninvasive
• Can be performed while
resuscitation ongoing
• Can be very sensitive
DISADVANTAGES OF FAST
• Operator dependent
• Body habitus may limit
quality/sensitivity
• Organ aspecific
• Can’t det...
Trauma Management
CARRY HOME MESSAGE
• Organised Team Approach
[There is no ‘I’ in TRAUMA]
• Initial Assessment & Management is the key
...
• ATLS Philosophy
• Primary Survey in 10 min
• C-Spine protection with
Philadelphia Collar
• Needle Cricothyroidotomy ...
• Primary Operative Control of haemorrhage
is preferred over Overaggressive Fluid
Resuscitation – Permissive Hypotension...
• Brief Neurological exam is enough initially
• Rule out organic causes for decreased
consciousness before thinking of d...
TRAUMA @ AHIH
• Trauma Team
• Trauma Protocol
• Training of Personnel
• Learning of Procedures
• In house/On call Con...
July 20 1969
• “From inability to Let well alone;
• from too much zeal for the new and
Contempt for what is old;
• from putting know...
A
Dharmendra
Presentation
Polytrauma ppt
Polytrauma ppt
Polytrauma ppt
of 117

Polytrauma ppt

How to approach polytrauma -- An overview
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Polytrauma ppt

  • 1. APPROACH & MANAGEMENT OF POLYTRAUMA Dr.K.R.Dharmendra., M.S[Gen.Surg].,D.N.B[Gen.Surg]., AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT
  • 2. OUTLINE  Concepts of trauma care  Principles of trauma management  ATLS Philosophy  Damage control surgery  Future directions
  • 3. EPIDEMIOLOGY  Trauma—commonest cause of death between 1-40  By 2020, injuries—third leading cause of death
  • 4. Definition of Polytrauma  2 or more body regions with SIRS
  • 5. SIRS  2 out of 4 signs Tachycardia >90 beats/min Tachypnoea >20 breaths/min Pyrexia >38 c[or hypothermia <36 c] WBC >12000/mcL or <4000/mcL
  • 6. SEPSIS SIRS with a proven infective source
  • 7. MODS Severe Sepsis CVS RS Kidney Liver Coagulation
  • 8. METABOLIC RESPONSE TO TRAUMA TWO PHASES EBB PHASE Role: conserve volume & energy for recovery & repair FLOW PHASE Role: mobilization of body resources
  • 9. EBB PHASE  Lasts for 24-48 hrs  Characterised by  Hypovolaemia  Decreased BMR  Reduced cardiac output  Hypothermia  Lactic acidosis
  • 10. FLOW PHASE Corresponds to SIRS Tissue oedema Increased BMR Increased cardiac output Leucocytosis, Raised body temperature Increased oxygen consumption Increased gluconeogenesis  Catabolic – 3-10 days  Anabolic - weeks
  • 11. METABOLIC RESPONSE TO TRAUMA
  • 12. PHARMACOLOGICAL IMMUNOMODULATION
  • 13. IMMUNO NUTRITION
  • 14. IMMUNO SUPPRESSION • Epidural anaesthesia • Statins • B blockers • Tranexamic acid
  • 15. GRADES OF HAEMORRHAGE
  • 16. REVISED TRAUMA SCORE
  • 17. “WELL BEGUN IS HALF DONE” • Initial assessment & management is critical in decreasing morbidity & mortality • Aids recovery
  • 18. THE GOLDEN HOUR
  • 19. TRIMODAL DEATH DISTRIBUTION
  • 20. TRIMODAL DEATH DISTRIBUTION
  • 21. PRINCIPLES OF TRAUMA MANAGEMENT • Organised team approach • Assumption of most serious injury • Treatment before diagnosis • Thorough examination • Frequent examination
  • 22. TRIAGE • In French, triage means “to sort” • Goals: • To identify the high risk injured patients • To channelise the transport of patients to appropriate centres
  • 23. 3 PHASES OF TRIAGE • Pre hospital Triage • At the scene of trauma • On arrival at hospital
  • 24. MULTIPLE CASUALTIES • The number & severity < Facility of the center • Priority is for life threatening injuries
  • 25. MASS CASUALTIES • The number & severity > Facility of the centre • Priority is for best chance of survival, least expenditure
  • 26. COMMUNICATION • Co ordination between pre hospital & hospital care • Timely preparation & mobilization of trauma team • Hemodynamic instability is also informed
  • 27. HAND OVER • Ambulance driver to Trauma team leader verbally MIST • Mechanism of Injury • Injuries suspected • Vital signs • Treatment en route to hospital
  • 28. TRAUMA TEAM • For better triage & care • Registrars from ED ICU Surgery Radiology Anaesthesiology • Theatre staff • Spokesperson
  • 29. ROLES SPECIFIED • Team Leader—Registrar from ED or ICU Airway Doctor • Plans interventions & treatment in consultation with Surgical Registrar [Traffic Controller & Information Collator] • Surgical Registrar—Circulation Doctor Procedure Doctor Secondary Survey
  • 30. ATLS PHILOSOPHY • Primary Survey & Resuscitation • Secondary Survey • Definitive Care
  • 31. PRIMARY SURVEY
  • 32. PRIMARY SURVEY • A—Airway Maintenance & Cervical spine protection • B—Breathing & Ventilation • C--- Circulation & Haemorrhage Control • D--- Disability: Neurological status • E--- Exposure & Environment protection
  • 33. C-SPINE PROTECTION Assume a cervical spine injury in any patient with multisystem trauma, especially with an altered level of consciousness, or a blunt or penetrating injury above the level of the clavicle
  • 34. PHILADELPHIA COLLAR • 35
  • 35. Airway Management Aims • When is the airway potentially threatened? • When is the airway compromised? • How do you treat and monitor? • What is a definitive airway?
  • 36. Predisposing Conditions • Coma • Aspiration • Maxillofacial trauma • Neck injury • Haematoma • Laryngeal injury • Thoracic inlet penetrating injury
  • 37. Signs of Airway Obstruction : "Look" • Agitation • Poor air movement • Rib retraction • Deformity • Foreign material
  • 38. Signs of Airway Obstruction : "Listen" • Speech? "How are you?" Hoarseness • Noisy breathing • Gurgle • Stridor
  • 39. Signs of Airway Obstruction : "Feel" • Fracture crepitus • Airway structures in neck • Tracheal deviation • Haematoma
  • 40. AIRWAY RESUSCITATION • Suction • Chin lift • Jaw Thrust • Oral airway • Definitive Airway
  • 41. • POLY5-34
  • 42. CHIN LIFT
  • 43. JAW THRUST
  • 44. When do you intubate the patient? • This is the definitive airway • Brain injury with GCS <8 • Severe multi system injury or haemodynamic instability • Facial burns or inhalational injury • Inability to closely monitor during ongoing resuscitation & investigation [ angio&CT] • Uncooperative or combative behavior
  • 45. Cricothyroidotomy INDICATIONS • Trauma causing oral, pharyngeal or nasal haemorrhage • Foreign body obstruction • Maxillo facial injuries
  • 46. Technical considerations • No surgical Cricothyroidotomy below 12 years • A permanent tracheostomy within 24 hrs • More than 2 days—higher risk of glottic stenosis
  • 47. NEEDLE CRICOTHYROIDOTOMY
  • 48. COMPLICATIONS EARLY • Bleeding • False passage • Subcutaneous emphysema • Oesophageal perforation • Vocal cord injury
  • 49. LATE • Infection • Glottic & Subglottic stenosis • Tracheo oesophageal fistula
  • 50. BREATHING & VENTILATION Abnormal Breathing : Look • Cyanosis • Decline in mental state • Chest asymmetry • Tachypnoea • Distended neck veins • Paralysis • Chest wounds • Flial segment
  • 51. Abnormal Breathing : Listen • I can't breathe! • Stridor, wheezing • Decreased breath sounds
  • 52. Abnormal Breathing : Feel • Surgical emphysema • Chest tenderness • Trachea deviated • Percussion & Auscultation
  • 53. DEADLY DOZEN THREATS FROM CHEST INJURY Immediately Life Threatening • Airway Obstruction • Tension Pneumothorax • Pericardial Tamponade • Open Pneumothorax • Massive haemothorax • Flial Chest
  • 54. Potentially Life Threatening • Aortic Injuries • Tracheo bronchial Injuries • Myocardial Contusion • Rupture of Diaphragm • Oesophageal injuries • Pulmonary Contusion
  • 55. SEALING OF OPEN WOUND
  • 56. Tension Pneumothorax • Not a radiological diagnosis; only clinical • Put a needle in 2nd ICS in MCL • Later ICD at 5th ICS in mid axillary line
  • 57. TENSION PNEUMOTHORAX
  • 58. HAEMOTHORAX • ICD INDICATIONS OF THORACOTOMY • Initial 1500 ml • 200 ml for 3 consecutive hours
  • 59. FLIAL CHEST • Rib fractured at 2 different places • Paradoxical chest movements • Underlying lung contusion • Positive pressure ventilation • Rarely surgical fixation is necessary
  • 60. CIRCULATION & HAEMORRHAGE CONTROL • Surgical Registrar & procedure nurse apply pressure bandage to open wounds Signs: • Deteriorating conscious level • Pallor • Rapid , thready pulse
  • 61. Is the heart beating? • Is there serious external bleeding? • Does patient have radial pulse? • Absent radial = systolic BP < 80 • Does patient have carotid pulse? • Absent carotid = systolic BP < 60
  • 62. Is patient perfusing? • Cool, pale, moist skin • Capillary refill > 2 sec • Restlessness, anxiety, combativeness If internal hemorrhage, quickly expose, palpate abdomen, pelvis, thighs
  • 63. THE STRATEGY • Primary Haemorrhage Control and timely surgical intervention rather than Overaggressive Fluid Resuscitation [ Permissive Hypotension ]
  • 64. THE PROCEDURES • IV access by procedure doctor • 2 wide bore cannula - 14 G or 16 G • Scalp bleeding—running locked sutures • Open fractures—direct pressure, reduction& splinting • No blind clamping of vessels • Angiography & embolisation
  • 65. CAUSES OF MAJOR BLEEDING MAJOR BLEEDING -THE BIG FIVE • EXTERNAL • THORACIC • PELVIC • LONG BONES • ABDOMEN
  • 66. FLUID THERAPY • Crystalloid fluid is preferred • Class 3 &4 shock—colloid fluid advised • Bolus of 1 litre of RL given
  • 67. 3 RESPONDERS • Rapid Response Be careful, these patients may still require surgery and may become "unstable" again! • Transient Response Stop the bleeding! • Minimal Response Remember the "Big 5"! Go to the operating theatre!
  • 68. Investigations for tissue perfusion
  • 69. Transfusion Guidelines
  • 70. Transfusion Guidelines • HCT < 21 • Lesser HB trigger in Asymptomatic patients • Higher HB trigger in severe CV diseases
  • 71. Why RL is preferred over NS • RL gives a hypercoagulable state • NS causes hyperchloremic acidosis • Significant difference in HCT • NS decreases FVIIa & FVIIa- Tissue Factor Complex • But in Head injury, RL may cause cerebral oedema • In patients taking metformin, chance of metabolic alkalosis is there if you use RL
  • 72. METABOLIC ACIDOSIS • Decreases Cardiac contractility • Decreases effectiveness of circulating catecholamines • Inhibits propagation phase of thrombin generation • Accelerates Fibrinogen degradation • Hyperchloremia causes renal vasoconstriction- decrease in GFR
  • 73. DISABILITY & NEUROLOGICAL EXAMINATION • Level of Consciousness = Best brain perfusion sign • Use AVPU initially • Check pupils • Eyes are the window of the CNS
  • 74. Brief Neurologic Examination • A–Alert • V –Responds to Vocal stimuli • P–Responds to Painful stimuli • U–Unresponsive More detailed evaluation -during the Secondary Survey
  • 75. Decreased LOC • Brain injury • Hypoxia • Hypoglycemia • Shock • Never think drugs, alcohol, or personality first
  • 76. GCS EEYYEE OOPPEENNIINNGG VVEERRBBAALL MMOOTTOORR SSppoonnttaanneeoouuss 44 OOrriieenntteedd 55 OObbeeyyss 66 VVeerrbbaall 33 CCoonnffuusseedd 44 LLooccaalliisseess 55 PPaaiinn 22 WWoorrddss 33 WWiitthhddrraawwss 44 NNoonnee 11 SSoouunnddss 22 DDeeccoorrttiiccaattee 33 NNoonnee 11 DDeecceerreebbrraattee 22 NNoonnee 11
  • 77. DISABILITY INTERVENTIONS • Spinal cord injury –High dose steroids if within 8 hours • ICPmonitor-Neurosurgical consultation • Elevated ICP –Head of bed elevated –Mannitol –Hyperventilation –Emergent decompression
  • 78. Exposure&Environmental protection • Complete disrobing of patient • Logroll to inspect back • Rectal temperature • Warm blankets/external warming device to prevent hypothermia
  • 79. Always Inspect the Back
  • 80. PAUSE & CHECK • Are all immediately life-threatening injuries identified? • Is all monitoring in place? • Investigations ordered? • Analgesia? • Relatives informed? • Non-essential team members disbanded?
  • 81. The well practiced trauma team should aim to complete the primary survey in less than 10 minutes
  • 82. Adjuncts to Primary Survey • ECG monitoring • Urinary and Gastric Catheters • Monitoring • X-rays and Diagnostics Studies
  • 83. Monitoring 1. Ventilatory rate and ABG • Monitor the adequacy of respiration • Confirm the ETT location 2. Pulse oximetry Measure of oxygen saturation of Hb • Should not be placed distal to the blood pressure cuff 3. Blood pressure
  • 84. X-rays and Diagnostics Studies • Chest x-ray AP • Pelvis AP • Lateral C-spine • DPL or FAST • Films can be taken in resuscitation area, usually with portable x-ray • Should not interrupt the resuscitation process
  • 85. INDICATIONS FOR ICU ADMISSION Requirement for: • Airway protection and mechanical ventilation • Cardiovascular resuscitation • Severe head injury • Organ support • Correct coagulopathy • Invasive monitoring
  • 86. SECONDARY SURVEY
  • 87. SECONDARY SURVEY • Does not begin until the primary survey (ABCDEs) is completed • Complete history • Head-to-toe evaluation • Reassessment of all vital signs
  • 88. HISTORY A - Allergy M- current Medication P- Past illness and operation L- Last meal E- Event and Environment related to the injury
  • 89. A Complete “Head to Toe’ examination • HEENT: scalp, eyes, ears, face, throat • Neck: distended neck veins, trachea midline, posterior midline deformity • Chest wall: flail segment, breath sounds • Abdomen: scaphoid or distended, tender • Pelvis: stable or unstable • Genitourinary: blood, bruising • Rectal: tone, blood • Back: spinal deformity, exit wounds • Extremities: deformity, pulses • Neurologic: GCS,feels all four/moves all four
  • 90. LOG ROLLING • 4 Persons required • 1 - Spinal inline traction [anaesthesiologist] • 2 -Torso • 3- Pelvis & Lower limb • 4- Detailed examination of back
  • 91. EXAMINATION OF BACK • Examine entire spine • Any penetrating injury or exit wound • Appropriate Dressing • Palpation of posterior chest wall • Percussion & Auscultation of post.chest
  • 92. SECONDARY SURVEY ‘Tubes and fingers in every orifice’
  • 93. Adjuncts to the Secondary Survey • Further investigation for specific injuries after stabilising the patient • x-ray spine and extremities • CT scan • contrast urography and angiography • Transesophageal ultrasound • Bronchoscopy • Esophagoscopy
  • 94. RE-EVALUATION • Continuous monitoring of vital signs, Hct • urinary output: adult keep > 0.5 mL/kg/hr children keep > 1 mL/kg/hr • Arterial blood gas • Cardiac monitoring • Pulse oximetry • End tidal CO2 • Relief of severe pain and anxiety IV opiates and anxiolytics
  • 95. DPL
  • 96. INDICATIONS FOR DPL • Equivocal abdominal sign • Unexplained hypotension • Impaired mental status • Paraplegia or spinal cord injuries
  • 97. CONTRAINDICATIONS FOR DPL Absolute contraindication • existing indication for explore laparotomy Relative contraindications • Previous abdominal operation • Morbid obesity • Advance cirrhosis • Coagulopathy
  • 98. CRITERIA FOR POSITIVE DPL > 10 ml of gross blood in blunt trauma • RBC count >100,000 /mm3 for blunt trauma • RBC count >10,000/mm3 for penetrating trauma • WBC count > 500/mm3 • Amylase > 200u/ml • Smear show bacteria or enteric content
  • 99. DPL
  • 100. DPL Advantages • Fast • Sensitive • Can be performed while resuscitation ongoing Disadvantages • Invasive • Learning curve • Not Organ specific
  • 101. FAST
  • 102. FAST • Detect intra abdominal fluid • Rapid, noninvasive, accurate, inexpensive, can repeat frequently • Indications same as DPL • Factors that compromise its utility are obesity, presence of subcutaneous air, previous abdominal operation
  • 103. FAST
  • 104. ADVANTAGES OF FAST • Fast • Noninvasive • Can be performed while resuscitation ongoing • Can be very sensitive
  • 105. DISADVANTAGES OF FAST • Operator dependent • Body habitus may limit quality/sensitivity • Organ aspecific • Can’t detect Hollow viscous and retroperitoneal injuries
  • 106. Trauma Management
  • 107. CARRY HOME MESSAGE • Organised Team Approach [There is no ‘I’ in TRAUMA] • Initial Assessment & Management is the key • Interferon –gamma, Epidural Anaesthesia & Early enteral nutrition • Appropriate Triage according to resources • Communication is pivotal for better preparation or Trauma Team
  • 108. • ATLS Philosophy • Primary Survey in 10 min • C-Spine protection with Philadelphia Collar • Needle Cricothyroidotomy – Ideal in emergency situations where Intubation is not feasible • Tension Pneumothorax is a clinical diagnosis; Immediate needling should be done
  • 109. • Primary Operative Control of haemorrhage is preferred over Overaggressive Fluid Resuscitation – Permissive Hypotension • No blind clamping of vessels • Angio embolisation is an important tool in controlling haemorrhage • Fluid challenge of 1 L RL is preferred • Serum lactate level & mixed venous saturation are the most indicators of tissue perfusion • If HB<7 & HCT<21- Transfusion indicated
  • 110. • Brief Neurological exam is enough initially • Rule out organic causes for decreased consciousness before thinking of drugs, alcohol & personality • Examination, Resuscitation & monitoring should go hand in hand • Head to Foot Secondary Survey is important to find out the missed injuries; Done by Surgical Registrar • “Tubes & Fingers in every orifice” –Theme of Secondary Survey • DPL & FAST come in handy in equivocal abdominal signs & Unexplained Hypotension • Damage Control Surgery is the weapon to tackle the “Triad of Death”
  • 111. TRAUMA @ AHIH • Trauma Team • Trauma Protocol • Training of Personnel • Learning of Procedures • In house/On call Consultants
  • 112. July 20 1969
  • 113. • “From inability to Let well alone; • from too much zeal for the new and Contempt for what is old; • from putting knowledge before Wisdom, • science before Art, • and cleverness before Common sense, • from treating patients as cases, • and from making the cure of the disease more grievous than the Endurance of the same, • Good Lord, deliver us.” --Sir Robert Hutchison
  • 114. A Dharmendra Presentation

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