Approach To Polytrauma

Suraj Kr Rauniyar
NMCTH, 1st yr
 Definition
 Poly trauma is a syndrome of multiple injuries with
systemic traumatic reactions which may lead to
dysfunction of remote organs and vital systems.

Multiple trauma
1. 2 cavities or 1 cavity + 2 major fractures
2. 2 or more injuries in combination i.e life threatening
3. Major trauma with ISS ≥ 16
World wide No.1 cause of death amongst the
younger age group (18-44 yrs).
Third most common cause of death in all age
groups.
 Death in polytrauma
• Immediate trauma death/First peak of
death.( Severe head injury, Brain stem injury,
High cord injury, Heart and major vessel injury,
Massive blood loss)
• Early trauma death /Second peak of death
(Intracranial bleed, Chest injury, Abdominal
bleeding, Pelvic bleeding , Multiple limb injury)
• Late death /Third peak of death – Sepsis and
Organ failure
 AIMS IN MANAGEMENT
“TO RESTORE THE PATIENT BACK TO
HIS PRE-INJURY STATUS”

Salvage life
Salvage limb
Salvage of total function if possible
 Pre–Hospital Management
Organization

Safety on scene

Immediate actions and Triage

Assessment and initial management

Extrication and Immobilization

Transfer to Hospital
 Management at Hospital

1. Organization
2. Trauma teams
3. Assessment and management – the
ATLS concept
- Initial assessment and management
- Definitive, systemic management.
 TRIAGERe shorting
Based on primary survey, level conciousness and vitals mainly

 Priority 1 Immediate
 Priority 2 Urgent
 Priority 3 Delayed
 Priority 4 Dead
1. Organization: aim-is to ‘get the right
patient to the right hospital in the right amount of time’

2. TEAM FOR POLY TRAUMA

• Team Leader – General Surgeon
• Orthopaedic surgeon
• Neuro surgeon
• Thoracic surgeon
• Accident and emergency medical officer
• Urologist
• Anesthesiologist
 Assessment and management –
ATLS concept

1. Primary survey and simultaneous

resuscitation – a rapid assessment and
treatment of life-threatening injuries.
2. Secondary survey – a detailed, head-to-toe
evaluation to identify all other injuries.
3. Definitive care – specialist treatment of
identified injuries.
Primary survey and resuscitation

The Awareness Recognition Management (ARM) system enables the

treating doctor to focus rapidly on the likely problems; for example:
 Awareness – A head injury is the most likely cause of unconsciousness
and obstructed airway in trauma casualties. Coma therefore alerts
the practitioner to the likelihood of airway obstruction.
 Recognition – An obstructed airway is recognized by looking,
listening and feeling for the diagnostic signs.
 Management – The airway is established with simple ‘bare hands’
manoeuvres, airway adjuncts, advanced airway interventions or
surgical airway techniques.
 A – AIRWAY AND CERVICAL SPINE CONTROL

The cervical spine is stabilized immediately on the basis that an

unstable injury cannot initially be ruled out.
Management

Chin lift jaw thrust

Jaw thrust with O2 mask

 OROPHARYNGEAL
AIRWAY:GUEDELS NASOPHARYNGEAL AIRWAY

SUPRAGLOTTIC AIRWAY
 B – BREATHING
A clear airway does not mean the casualty is breathing
adequately to enable peripheral tissue oxygenation.
Maintenance by giving high oxygen flow 15L/min
When to ventilate??
 Apnoea • Hypoventilation
• Flail chest • High spinal cord injury •
Diaphragmatic injury • Head injury GCS<8
• Hypercapnea • Hypothermia
 Management
1 Tension pneumothorax-
Immediate management(needle thoracocentesis)
definitivete management(thoracostomy)
2 Open pneumothorax (sucking chest wound)
occlusive dressing or specialist valved dressing
3 Massive haemothorax
open thoracostomy followed by insertion of a chest drain
4 Cardiac tamponade-
needle pericardiocentesis or pericardotomy via a clamshell
thoracotomy
5 Flail chest- oxygen and analgesia.
6 Disruption of tracheobronchial tree-
tracheal intubation/endobronchial intubation of the opposite lung
 C – CIRCULATION WITH
HAEMORRHAGE CONTROL
CAUSES OF MAJOR BLEEDING
• External bleeding
• Thoracic bleeding
• Pelvic bleeding
• Intra-abdominal bleeding
• Long bones fracture bleeding
 AMOUNT BLOOD LOSS
Bone fracture Estimated blood loss(ML)

RIB 125

RADIUS OR ULNA 250-500 each

HUMERUS 500-750 each arm

TIBIA OR FIBULA 500-1000 each leg

FEMUR 1000-2000 each leg

PELVIS ATLEAST 1000 BUT OFTEN >2L

 Management
 External bleeding - Inspect and apply local pressure
• Thoracic bleeding take Chest X-ray and Intercostal
drainage (ICD) tube insertion.
• Pelvic bleeding take Pelvis X-ray and apply pelvic
binder or external fixator
• Intra-abdominal bleeding is confirmed by Clinical
finding, USG, CT scan and Doppler study Emergency
laparotomy
• Long bones fractures can be fixed or splintage can be
applied.
 Maintenance of circulation
I.V. Fluids one above and one below the diaphragm (Crystaloids
and colloids)
Classification of haemorrhage and fluid replacement

CLASS CHANGES REPLACEMENT

I : </ 15% of blood No change in pulse , blood 1.5 L –RL or 1 L - Polygelatin

volume volume or pressure (haemaccel)

II: 15-30% of blood Increase in pulse no change in 1.5 L –RL or 1 L - Polygelatin

volume pressure (haemaccel) some may need
blood transfusion

III: 30-40% of blood Tachycardia and loss of Systolic Patients are given 2 litres of
volume blood pressure and crystalloids over 20 min blood
decreased mental status. trasnsfusion in necessary

IV: >/ 40% of blood Marked tachycardia, << sys Bp, Consider 2-3 units of FFP and a
volume anuria/oliguria, cold and pale six pack of platelets
skin, decreased mental status for every 5 liter of volume
replacement.
 D – DISABILITY
The key element of assessing a patient’s neurological
status is the Glasgow Coma Score(GCS)
SCORE EYE VERBAL MOTOR

1 NIL NIL NO MOVEMENT

2 ON PAIN SOUNDS ABNORMAL EXTENSION

3 On command WORDS ABNORMAL FLEXON

4 SPONTANEOUS CONFUSED WITHDRAWS PAIN

5 ORIENTATED LOCALIZE PAIN

6 OBEYS

MAXIMUM 15/15 MINIMUM 3/15 CRITICAL <= 8/15

If GCS IS <= 10/15 CT HEAD IS INDICATED
The pupils are examined for any difference in size
indicating possible raised, intracerebral pressure(ICP),
and unresponsive pupils, fixed at midpoint, which can
indicate serious brain damage.

E – EXPOSURE AND ENVIRONMENT

The patient should have all clothing removed to enable a full

examination of the entire body surface area to take place.
This will require log-rolling to examine the posterior aspects
and allow removal of any glass or debris. The casualty should
be kept warm to maintain body temperature as close to 37
°C as possible.
ADJUNCTS TO PRIMARY SURVEY
 Vital signs
 ECG
 Pulse oximetry
 End-tidal carbon dioxide
 Arterial blood gases
 Urinary output
 Urethral catheter (unless contraindicated)
 Nasogastric tube (unless contraindicated)
 X-RAY (trauma series)
– C-Spine lateral, Chest X Ray, Pelvic film, Lumbosacral
and affected part if so present
Note: Essential X-ray’s should not be avoided in
pregnant patient.
 SECONDARY SURVEY
Patients shows normal vital sign after primary survey and
resuscitation Head to toe evaluation & reassessment of all vital signs.
A complete neurological examination is performed including Glasgow
Coma Score.

Components:
• the history
• physical examination
• neurological examination
• further diagnostic tests
• re-evaluation.
1. History: Event at scene, comorbities
AMPLE: allergies; medications; past illnesses; last meal; events
and environment.
2.Examination: LOOK-LISTEN- FEEL
Head to toe examination and
 Neurology A rapid neurological assessment is carried out to
detect lateralizing signs, loss of sensation and motor power,
and abnormality of reflexes. Levels of sensory loss should be
carefully documented to enable deterioration or improvement
to be quantified.
X-rays and CT may be indicated to detect spinal fractures
E-FAST for- blunt trauma abdomen, cardiac tamponade and
haemothorax/ pneumothorax.
 MANAGEMENT OF LIFE
THREATENING ORTHOPAEDIC
INJURIES
 ZERO HOUR FIXATION

• All poly trauma patients with injuries of other organs like

spleen, Liver, Kidney
• Major blood vessel tear
• Depressed skull fractures
• Pelvic fractures
 TRANSPORT

• All Fracture sites - should be

splinted.
• Back board (or) scoop stretcher
used.
• Log - Rolling method to be avoided.
• Board traction devices available.
 SPINAL INJURIES
Suspected patients of spinal
injury - immobilised
• Cervical collar
• Spine board
 In all patients with spinal injury, maintain
spinal precautions
 until thorough clinical and radiographic
evaluation of spine is completed.
• Spine is no more called as no man’s area.
• Stabilization of spine is mandatory.
 Prevention of bed sore.
 Early mobilization & Rehabilitation.
 PELVIC INJURIES
 Pelvic injury is one of the major cause for death
• Pelvic injuries are assessed during secondary
survey
• Pelvis X-Ray is mandatory in polytrauma patient
• Can lead to life threatening hemorrahge – 50%
mortality
• Urethral injury – transurethral or suprapubic
catheter can be used.
 IMMEDIATE MANAGEMENT OF
SEVERE PELVIC BLEEDING
 Pelvic binders, MAST (Military anti shock
trousers),Pneumatic anti shock garment
 External fixator
 Pelvic packing
 Angiographic Embolisation
 BINDERS/MAST

Advantages:
 Reduce the pelvic volume
• Allows clot formation
• Allow for auto transfusion

Disadvantages:
• Compartment syndrome and skin necrosis.
External fixator
 Pelvic packing
• Done during
laparotomy.
• In uncontrolled pelvic
bleeding associated
with abdominal
injuries .
• During packing
always stabilise the
pelvis with external
fixators.
 Angiographic
embolization

• Success rate reported in the >

95%
• Most arterial injuries involve
the internal iliac artery.
• Multiple bleeding sites in 40%
of patients.
• Most common branches :
sup gluteal,internal pudendal,
inferior gluteal, obturator.
 FAT EMBOLISM SYNDROME
 Common cause fracture of long bone and liposuction
 Fat embolism incidence in a polytrauma -30-90%
 Classic triad hypoxemia, neurological abnormalities
and petechial rash.
Early warning signs of fat embolism (usually
within 72 hours of injury) are a slight rise of
temperature and pulse rate

There is no infallible test for fat embolism;

however, urinalysis may show fat globules in
the urine and the blood PO2 should always be
monitored.
Management of severe fat embolism
(supportive)
Supplement with high concentrated oxygen
prompt stabilization of long-bone fractures
Intramedullary nailing is not thought to
increase the risk of developing the syndrome.
Fixation of fractures also allows the patient
to be nursed in the sitting position, which
optimizes the ventilation–perfusion match in
the lungs
 Summary

 Polytrauma must be considered as a systemic surgical

disease
 Primary objective is survival of patients
 Early fixation of major fractures – performed with
right concept has proved to be an important tool to
obtain this primary objective.
 References

 Apley’s 10th edition

 Campbel’s operative orthopaedics 2017
 Wikipedia
 AHA pdf
THANK YOU