POLYTRAUMA
Objectives
Prioritize and initiate assessment of the
traumatized patient
Initiate treatment of life-threatening
traumatic injury
Utilize radiography in identifying
significant traumatic injury
Identify and respond to changes in
status of the injured patient
Identify patients requiring transfer to a
higher level of care
POLYTRAUMA
Defined as a clinical state following injury to the body leading to
profound physiometabolic changes involving multisystem.
OR
Patient with anyone of the following combination of injuries
TWO MAJOR SYSTEM INJURY + ONE MAJOR LIMB INJURY.
ONE MAJOR SYSTEM INJURY + TWO MAJOR LIMB INJURY.
ONE MAJOR SYSTEM INJURY + ONE OPEN GRADE III
SKELETAL INJURY.
UNSTABLE PELVIS FRACTURE WITH ASSOCIATED
VISCERAL INJURY.
Polytrauma is not synonym of multiple fractures.
Multiple fractures are purely orthopaedic problem as there is
involvement of skeletal system alone.
Statistics
Trimodal death distribution
First peak instantly (brain, heart, large vessel
injury)
Second peak minutes to hours (golden hour)
3rd peak weeks later of late complications and
organ failure
If preventive measures are taken 70% deaths
can be prevented, means 30% deaths are
nonsalvagable deaths
The Golden Hour
The Golden Hour is a theory stating that the
best chance of survival occurs when a
seriously injured patient has emergency
management within ONE hour of the injury.
Platinum 10 minutes : Only 10 minutes of the
Golden Hour may be used for on-scene
activities
ATLS
TREAT LETHAL INJURY FIRST, THEN
REASSESS AND TREAT AGAIN
TRIAGE
Triage is the sorting of patients based on
the need for treatment and the available
resources to provide that treatment
Trauma Team
Case Study 1
Unrestrained man ejected after his car
collided with a large truck
Incoherent and unable to clear secretions
Femur fracture, scalp laceration, chest and
abdominal contusions
BP 90/60 mm Hg, HR 125/min, RR 35/min
Lethargic with cool, clammy skin
What does the primary survey indicate?
Trauma Management
Primary assessment
Initial evaluation and resuscitation
Secondary assessment
Diagnosis and treatment of other
injuries
Tertiary assessment
Ongoing evaluation
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Primary Assessment
Airway maintenance with cervical spine
precautions
Breathing: oxygenation and ventilation
Circulation with hemorrhage control
Disability: brief neurologic examination
Exposure/environment: undress, avoid
hypothermia
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Case Study 1
Incoherent, unable to clear secretions
Femur fracture, scalp laceration, chest
and abdominal contusions
BP 90/60 mm Hg, HR 125/min,
RR 35/min
No eye opening to stimuli, lethargic,
all extremities withdrawn to pain
Cool, clammy skin
A
B
C
D
E
What interventions are most important?
What does the primary survey indicate?
Copyright 2012 Society of Critical Care Medicine
12
Airway and Breathing Issues
Establish airway patency
Airway control: intubation, adjunctive
device, surgical airway
Oxygenation and ventilation
Cervical spine stabilization
13
Airway Interventions
Supplemental oxygen
Suction
Chin lift/jaw thrust
Oral/nasal airways
Definitive airways
RSI for agitated patients with c-spine
immobilization
ETT for comatose patients (GCS<8)
Flail Chest
Subcutaneous Emphysema
What would we do for this
patient who is having difficulty
breathing?
Case Study 1
Incoherent, unable to clear secretions
Femur fracture, scalp laceration, chest
and abdominal contusions
BP 90/60 mm Hg, HR 125/min,
RR 35/min
No eye opening to stimuli, lethargic, all
extremities withdrawn to pain
A
B
C
D
E
Cool, clammy skin
Is this patient in shock?
What interventions are indicated?
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Shock in Trauma
Hemorrhagic
Chest
Abdomen
Pelvis
Femur
Nonhemorrhagic
Obstructive: tension pneumothorax,
cardiac tamponade
Neurogenic: spinal cord injury
Cardiac: blunt injury
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C- Circulation
Hemorrhagic shock should be assumed in
any hypotensive trauma patient
Rapid assessment of hemodynamic status
Level of consciousness
Skin color
Pulses in four extremities
Blood pressure and pulse pressure(narrow)
Haemorrhage
Hemorrhage Classification
BP 90/60 mm Hg, HR 125/min, RR 35/min
Variable
Class I
Class II
Class III
Class IV
HR, beats/min
<100
>100
>120
>140
RR, breaths/min
14-20
20-30
30-40
>35
anxious
agitated
Blood loss (mL)
<750
750-1,500
1,5002,000
>2,000
Blood loss (%)
<15
15-30
30-40
>40
Systolic BP
Mental status
Resuscitation
fluid
Oral or Crystalloi
d
crystalloid
confused lethargic
Crystalloi
d and
Blood and
crystalloid
blood
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Circulation Issues
Large bore peripheral IV cannulas (2) or IO
2 L warmed lactated Ringer solution (>50
mL/kg)
External hemorrhage control
Diagnostic studies for hemorrhage source
Red blood cell transfusion
Transfusion of other blood products
Monitoring
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Pelvic Binders
Case Study 1
Incoherent, unable to clear secretions
Femur fracture, scalp laceration, chest
and abdominal contusions
BP 90/60 mm Hg, HR 125/min,
RR 35/min
No eye opening to stimuli, lethargic,
all extremities withdrawn to pain
Cool, clammy skin
A
B
C
D
E
How would you assess disability?
What adverse effects occur from exposure?
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Glasgow Coma Scale
Score
1
Eye Opening
No
Response
To Pain
To Speech
Spontaneous
Best Verbal
Best Motor
No
Response
No Response
Incomprehen
Extensor
-sible
Inappropriate
Flexor
Disoriented
Oriented
GCS = 7
Withdraws to
Pain
Localizes Pain
Obeys
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Always Inspect the Back and
Perineum
Extradural Hematoma(EDH)
What disease process does this
indicate?
Case Study 1
Patient is intubated and mechanically
ventilated with 100% O2
Coarse rhonchi bilaterally
2 L lactated Ringer solution
administered
BP 104/78 mm Hg, HR 110/min, RR
18/min, SpO2 95%
What are the next steps in assessment?
Which laboratory and radiologic
tests should be obtained?
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Secondary Assessment
Detailed history
Head-to-toe physical examination
Laboratory studies
Radiologic studies
Other interventions
FAST
Diagnostic peritoneal lavage
Naso- or orogastric tube
Antibiotics
Tetanus status
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Case Study 2
Man with liver and mesenteric
lacerations from vehicular accident
Bowel resected and abdomen packed
to control bleeding
Fluid resuscitation continues
Airway pressures and urine output
after ICU admission
What are possible causes of airway
pressures and urine output?
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Tertiary Assessment
Head injury
Pulmonary injury
Cardiac injury
Abdominal injury
Musculoskeletal injury
Adequacy of resuscitation
Transfer
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Golden Rules of Trauma
All trauma patients need oxygen until proven
otherwise.
All trauma patients are bleeding until proven
otherwise.
All trauma patients have a cervical spine
injury until proven otherwise.
All unconscious/altered LOC trauma patients
have a brain injury until proven otherwise.
Conclusion
Readiness, hyper-vigilance, consistent
organization and clear cut communication
produces effective outcomes
We should all know our A, B, C, Ds
Practice makes perfect
The success of a trauma resuscitation is only
as good as its team AND
A proficient trauma team cannot function without
a well-skilled trauma nurse!
