Polytrauma

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Primary Survey

History (AMPLE)

Allergy, medication, past medical experience, last oral intake, events surrounding the injury.

PHYSICAL EXAMINATION

A team approach involving physicians, nurses, technicians & trained paramedical personnel allows resuscitation to occur while ongoing evaluation is conducted.  A full resuscitating team consists of 3 or even better 4 physicians & 1 anaesthetist, 3 nurses & one person to take required notes.  The most experienced surgeon acts as a captain of the team.  He directs the activity of everyone else in the emergency room.

It is vital that resuscitation & evaluation occur aggressively & simultaneously.  It involves a rapid assessment, resuscitation of vital signs, a more detailed secondary assessment & initiation of definitive care.

AIRWAY

Airway obstruction may manifest in a variety of ways e.g. inability to speak, stridor, abnormal upper airway sounds (snoring, gurgling or gargling), agitation, combativeness or obtundation.  The most common causes of airway obstruction are; tongue fall, foreign bodies, retained secretions and blood.

BREATHING

Progressive Hypoxia cerebral confusion, restlessness (mild hypoxia), rapid & shallow respiration with cyanosis (severe ventilatory interference).

Immediate Life Threatening Conditions Causing Ventilatory Failure ——Tension Pneumothorax: Clinical Features include external evidence of trauma, open sucking wounds, surgical emphysema, pain, paradoxical movements, stove-in chest, decreased movements on the affected side with hyper-resonant percussion note, reduced breath sounds in the axilla & shift of trachea to the opposite side, dullness to percussion, use of accessory muscles to breathe, haemoptysis & absence of breath sounds.

 

CIRCULATION

  • Look for haemorrhage (external or internal) and / or shock & its degree.
  • B.P., pulse and skin perfusion.  Dilated neck veins, muffled heart sounds (thoracic trauma).
  • Bradycardia, dry, warm skin, normal mental status (neurogenic shock).
  • Tachycardia, cool, clammy skin, altered mental status, low urinary output (haemorrhagic shock).
  • Abdominal pain, tenderness, rigidity (abdominal trauma).

MINI-NEUROLOGICAL EXAMINATION: AVPU

  • Patient awake & alert, appropriately or inappropriately responsive to stimuli or unconscious.
  • Utilize the component of Glasgow Coma Score.
  • Vomiting / episode of unconsciousness.

EXPOSURE

 

Complete exposure of the patient is required to allow adequate examination of all body areas for obvious injury but avoid hypothermia.

Cover the patient with a warm blanket.

RESUSCITATION

Airway Maintenance

Most common causes of airway obstruction are easiest to alleviate using maneuvers such as scooping, chin lift, suctioning, oropharyngeal or nasopharyngeal airway and placing oropharyngeal airway.

Airway obstruction may be progressive and recurrent.  Thus these maneuvers may need to be repeated frequently.  If they are primarily or secondarily unsuccessful, pass endotracheal tube.  Prolonged attempts at intubation should be accompanied by concomitant intermittent ventilation.

If unable to intubate, resort to crico-thyroidotomy/ tracheostomy.

 

Breathing

(Maintenance of Adequate Ventilation)

In case ventilation is hindered with

  • Start positive pressure breathing (Ambu bag or anesthesia machine).
  • Administer 100% oxygen.
  • For Tension Pneumothorax, insert a short wide-bore needle in the 2nd intercostal space 4 cm from the sternum & connect it to water seal. Then Inform The Registrar. Chest tube should replace it as soon as possible.
  • For Massive Pneumothorax,insertion of chest tube is required.
    • For Open Pneumothorax, close/seal the wound & insert chest tube.

For Major Airway Rupture, Lung Contusion & Aspiration, endotracheal intubation is required.

 

Circulation

Control haemorrhage & restore circulatory volume.

 

For External Haemorrhage, direct pressure & in case of bleeding from fracture site, splintage is required.

 

Haemorrhagic Shock

  • Establish vascular access.
  • Initiate fluid resuscitation with Ringer’s lactate / 0.9% sodium chloride.
  • When blood loss is more than 30% (1500 ml), the patient has a pulse rate of more than 120/min, with decreased B.P.& pulse pressure, fluid replacement is initiated.

Replacement fluids should be warmed prior to administration.

For Continued or Recurrent Hypotension, decision must be made whether there is cavitatory (intrathoracic or intraabdominal), or non-cavitatory (external bleeding / fractures) haemorrhage.

  • For Spinal Vasomotor Shock, add vasopressors.  Severe bradycardia will be treated with atropine 0.5 mg to 1 mg every 3-5 min, until the pulse is more than 60/min or to a total dose of 3 mg.

Hypotension will be treated with dopamine infusion titrated to a systolic BP just over 100 mmHg.

Cardiac Tamponade

Indications of Resuscitative Thoracotomy

Indications of Resuscitative Laparotomy

  • Rigid distended abdomen.
  • Therapy resistant (Non responder / transient responder) to hypovolaemic shock.
  • “Imprint Sign” of the abdominal wall or lower thorax.
  • Tender abdomen.

 

Brain Resuscitation

  • Mild hyperventilation.
  • Patient with Glasgow coma scale 8 or less or lateralizing signs are very likely to have an intracranial mass or lesion requiring prompt intubation and possible surgical intervention.

    extensive open wound requiring urgent management

 

Exposure

Avoid hypothermia.

 

Secondary Survey:

Detailed examination of all body systems.

Head and Neck

Identify penetrating wounds and closed maxillofacial injuries.

The Mouth is examined for retropharyngeal haematomas.

Cranial Nerves should be examined and findings recorded.

With axial immobilization, The Neck is examined for tenderness, bony steps-off or skin abrasions.

CHEST

Examine for crepitus, rib or sternal pain.

Abdominal Examination Bowel sounds may be absent.

Pelvic Examination

Pubic or iliac crest pain, pelvic instability or perineal haematomas.  Blood at the urethral meatus signifies urethral injury.

Rectal Examination for perianal soiling, tenderness, sphincter tone, mucosal breach, inability to palpate prostate, and finger smeared with blood.

Spine

Maintaining axial spine alignment, a detailed examination of the back of the chest and abdomen.  Tenderness, bony abnormalities or neurological deficits are especially looked for.

The Extremities

  • Examine for swelling and tightness of compartments.
  • Crepitus, skin integrity, the presence of peripheral pulses and neurological deficit.
  • Presence of bruits and expanding haematomas.

 

Re-Evaluation of patient’s consciousness, pupil size & GCS assessment.

Investigations

Draw blood samples. Urinalysis, radiographs, ultrasonography, ECG, diagnostic peritoneal lavage, CT scan, echocardiography, I/V urograms & angiography.

 

Management

  1. Pass nasogastric tube.
  2. Catheterize urinary bladder.
  3. Tetavax 0.5 ml IM. The need for tetanus immunization depends on the patient’s immunization status & the risk of wound.
  4. Inj. dicloran deep I/M injection 2-3 mg/kg per /day in divided doses.
  5. Ampiclox 1 gm I/V injection after sensitivity test.
  6. 6. DEFINITIVE CARE

The trauma management protocol is complete when definitive care has been instituted for each organ system injury.

 

MONITORING

Pain, B.P, pulse every 15-30 min, urine output hourly, respiratory distress, blood gases, mental status, ECG & body temperature.

 

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