POLYTRAUMA

POLY TRAUMA -ROLE OF ORTHOPAEDICS

1. POLYTRAUMA Director &HOD Prof.Dr . K.PRAKASAM M.S.ORTHO,D.ORTHO,DSc (HON) Moderator:Dr Hari PRESENTOR: DR.THOUSEEF .A. MAJEED

2. Definition Poly-trauma means a syndrome of multiple injuries with systemic traumatic reactions which may lead to dysfunction or failure of remote organs and vital systems. 1/18/2017 2

3. Polytrauma needs management by a team of surgeons and physicians. Orthopaedic surgeon is one of the team member of trauma unit. Orthopaedic injuries are generally not life-threatening unless they result in significant hemodynamic instability.

4. 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.

5. POLYTRAUMA Vs MULTIPLE FRACTURES Polytrauma is not a synonym of multiple fractures. Multiple fractures are purely orthopaedic problem as there is involvement of skeletal system While in polytrauma there is involvement of more than one system like associated head injury/ chest injury/ spinal injury/ abdominal or pelvic injury

6. Death in polytrauma Immediate trauma death/First peak of death. Early trauma death /Second peak of death . Late death /Third peak of death .

7. First peak of death/Immediate trauma death Severe head injury Brain stem injury High cord injury Heart and major vessel injury Massive blood loss

8. Second peak of death / Early trauma death Intracranial bleed Chest injury Abdominal bleeding Pelvic bleeding Multiple limb injury

9. Third peak of death / Late death It occurs after several days or weeks due to Sepsis Organ failure

10. AIMS IN MANAGEMENT “TO RESTORE THE PATIENT BACK TO HIS PRE-INJURY STATUS” HAVING FOLLOWING PRIORTIES: LIFE SALVAGE LIMB SALVAGE SALVAGE OF TOTAL FUNCTION IF POSSIBLE

11. LIFE SALVAGE 50% deaths due to trauma occurs before the patient reaches hospital . 30% occurs within 4 hrs of reaching the hospital . 20% occurs within next 3 weeks in the hospital . If preventive measures are taken, 70 % deaths can be prevented meaning 30% deaths are non- salvagable deaths.

12. TEAM OF CONSULTANTS FOR POLY TRAUMA Team Leader – General Surgeon Orthopaedic surgeon Neuro surgeon Thoracic surgeon Accident and emergency medical officer Urologist Anesthesiologist

13. Advanced Trauma Life Support (ATLS) Four inter related stages Rapid primary survey with simultaneous resuscitation Detailed secondary survey Constant re-evaluation Initiation of definitive care 1/18/2017 13

14. PRE-HOSPITAL PHASE BASIC EMERGENCY MEDICAL TECHNICIAN SKILLS Maintenance of Airway ( endotracheal intubation) Cardiopulmonary resuscitation Fluid replacement with isotonic solution Reduction and splintage of fractures Perform primary survey of patient and report findings to destination center

15. TRIAGE Triage is usually used in a scene of an accident or "mass-casualty incident”. To sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries.

16. Golden Hour Rapid transport of severely injured patient to a trauma center with in one hour Chances of survival diminishes after one hour Platinum 10 minutes : Only 10 minutes of the Golden hour may be used for on-scene activities 1/18/2017 16

17. PRIMARY SURVEY A – Air way maintenance with control of cervical spine B – Breathing & Oxygenation C – Circulation & Control of bleeding D – Disability E – Exposure & avoidance 1/18/2017 17

18. PRIMARY SURVEY Life threatening conditions are identified and management is instituted simultaneously Airway obstruction Tension pneumothorax Haemothorax Open thoracic injury and flail chest Cardiac tamponade Massive internal or external hemorrhage

19. LOOK AGITATION RIB RETRACTION DEFORMITY FOREIGN MATERIAL . LISTEN SPEECH? HOARSENESS. NOISY BREATHING GURGLE. STRIDOR. FEEL FEEL FOR CREPITUS. TRACHEAL DEVIATION. HEMATOMA. SIGNS OF AIRWAY OBSTRUCTION

20. WHEN TO VENTILATE Apnoea Hypoventilation Flail chest High spinal cord injury Diaphragmatic injury Head injury GCS<8 Hypercapnea Hypothermia

21. MAINTANENCE OF AIRWAY Mask O 2 Endo Tracheal-Intubation Ambu Bag Protection of the spine is very important while giving airway maintanence . 1/18/2017 21

22. CAUSES OF MAJOR BLEEDING External bleeding Thoracic bleeding Pelvic bleeding Intra-abdominal bleeding Long bones fracture bleeding

23. 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

24. 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.

25. Maintenance of circulation 1/18/2017 25 I.V. Fluids one above and one below the diaphragm ( Crystaloids and colloids)

26. Classification of hemorrhage 70 kg male ---5 litres of blood Class I Haemorrhage  - Loss of up to 15% of the blood volume does not cause a change in blood volume or pressure. Treated with 1.5 litres of Ringer lactate or 1 litre of Polygelatin ( haemaccel )

27. Class II Haemorrhage - loss of 15% to 30% of blood volume results in increased pulse but no change in blood pressure. Resuscitated with a crystalloid, but some may require blood transfusion. 1.5 Litres of Ringer lactate+ 1 Litre Haemaccel .

28. Class III -haemorrhage Loss of 30% to 40% of circulating blood (2 litres) Tachycardia and loss of Systolic blood pressure and decreased mental status. Patients are given 2 litres of saline over 20 min. Blood pressure should be maintained with crystalloid until blood is ready. Recurrent hypotension- 2liters of crystalloid + type-specific or non–cross-matched universal-donor (i.e., group O neg ) blood is given.

29. Class IV -Haemorrhage Loss of more than 40% of blood volume. Marked tachycardia, significantly decreased systolic blood pressure, cold and pale skin, severely decreased mental status,negligible urine output. Consider 2-3 units of FFP and a six pack of platelets for every 5 liter  of volume replacement.

30. DISABILITY ( NEUROLOGICAL EVALUATION) 50% of trauma deaths are due to head injuries To describe the level of consciousness A : Alert V : Responds to vocal stimuli P : Responds to painful stimuli U : Unresponsiveness' to all stimuli

31. GLASGOW COMA SCORE Normal – 15/15 If GCS <10 CT brain is indicated

32. STRATEGY IN PATIENTS WITH HEAD INJURY Beware of the fact that cerebral auto regulation goes off following head injury. Extensive sympathetic block due to regional anaesthesia may hamper Cerebral Blood Flow Severe head injury → only life saving procedures

33. STRATEGY IN PATIENTS WITH CHEST INJURY Rib fracture or lung contusion Monitoring with pulse oximeter or ABG Incidence of Acute Respiratory Distress Severe chest injury →only life saving procedures

34. ADJUNCT TO PRIMARY SURVEY & RESUSCITATION ELECTRO-CARDIOGRAPHIC MONITORING URINARY CATHETER & RYLES TUBE if necessary X-RAY C-Spine lateral, Chest X Ray, Pelvic film (trauma series) Essential X-ray’s should not be avoided i n pregnant patient.

35. 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 S core.

36. MANAGEMENT OF LIFE THREATENING ORTHOPAEDIC INJURIES

37. 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

38. TRANSPORT All Fracture sites - should be splinted. Back board (or) scoop stretcher used. Log - Rolling method to be avoided. Board traction devices available.

39. SPINAL INJURIES Suspected patients of spinal injury - immobilised Cervical collar Spine board

40. 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.

41. 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.

42. IMMEDIATE MANAGEMENT OF SEVERE PELVIC BLEEDING 1 Pelvic binders, MAST (Military anti shock trousers),Pneumatic anti shock garment 2 External fixator 3 Pelvic packing 4 Angiographic Embolisation

43. BINDERS/MAST Reduce the pelvic volume Allows clot formation Allow for auto transfusion Disadvantages: Compartment syndrome and skin necrosis.

44. 1/18/2017 46

45. PELVIC PACKING Done during laparotomy . In uncontrolled pelvic bleeding associated with abdominal injuries . During packing always stabilise the pelvis with external fixators.

46. ANGIOGRAPHIC EMBOLISATION Success rate reported in the > 95% Most arterial injuries involve the internal iliac artery. Multiple bleeding sites in 40% of patients. Most common branches : superior gluteal, lareal sacral,internal pudendal , inferior gluteal, obturator .

47. Complication rate: 0- 6%. Complications: Liver necrosis Skin necrosis Nerve damage Femoral head necrosis Bladder necrosis Sexual dysfunction.

48. “ DAMAGE CONTROL ORTHOPAEDICS”

49. DAMAGE CONTROL SURGERY Rapid emergency surgery to save life or limb Not involving complex reconstructive surgery Control bleeding Decompress cranium, pericardium, thorax, abdomen and limbs Decontaminate wounds and ruptured viscera Splint fractures Cast, traction, pelvic binder, ex-fix

50. THE ‘FIRST HIT’ Threshold for fatal inflammatory response DEATH: from multiorgan failure or adult respiratory distress syndrome 1 st Hit: the trauma inflammatory response time The ‘natural’ systemic inflammatory response

51. THE ‘SECOND HIT’ (2-5 DAYS) Severe trauma can result in a life threatening inflammatory response (SIRS) Threshold for fatal inflammatory response DEATH: from multiorgan failure or adult respiratory distress syndrome 1 st Hit: the trauma inflammatory response time 2 nd Hit: the surgery The exaggerated response brought about by the 2 nd hit of surgery

52. THE ‘SECOND HIT’ (2-5 DAYS) Severe trauma can result in a life threatening inflammatory response (SIRS) Threshold for fatal inflammatory response DEATH: from multiorgan failure or adult respiratory distress syndrome 1 st Hit: the trauma inflammatory response time 2 nd Hit: the surgery In some individuals the lengthy surgery of early total care exacerbates the the systemic inflammatory response resulting in death

53. Patients For Damage Control Surgery Stable Borderline Unstable Extreme

54. Damage Control Surgery Patients STABLE No life threatening injuries, haemodynamically stable Early total care BORDERLINE Initially respond to resuscitation but can detoriate Wait for improvement UNSTABLE Remain hemodynamically unstable despite initial resuscitation Damage control surgery EXTREME Close to death uncontrollable blood loss Damage control surgery or ITU

55. SERUM LACTATE LEVELS Initial lactate: < 2.5 mg/ dL -Chance of mortality is 5.4% 2.5 mg/ dL to 4.0 mg/ dL --- 6.4% Mortality >=4.0 mg/ dL --- 18.8 % Mortality

56. Lactate controlled early total care Often high in 1 st few hours but will drop if resuscitation is adequate 2.5 magic number! < 2.5 Early Total Care. 2.5 – Look at TREND( Trauma related Neuronal dysfunction) > 3 Damage Control Surgery

57. EARLY TOTAL CARE Definitive fracture treatment within 24hr Only in stable patients, lactate < 2.5 Avoid in thoracic injuries, hemorrhagic shock and head injury Advantage – pain relief, less infection early mobilisation and prevention of thromboembolism.

58. Priorities in surgical management of musculoskeletal injury Save life Save limb Save joints Restore function 1/18/2017 60

59. PRIORITIES IN FRACTURE CARE Pelvis Spine Femur Tibia Upper extremity

60. Aims for fracture management Control of sources of contaminations Removal of dead issue Prevention of ischemia Pain relief Facilitation of intensive care

61. Fat embolism incidence in a polytrauma -30-90 % If surgery is performed following polytrauma , will reaming further increase the incidence of Fat Embolism . FAT EMBOLISM IN POLYTRAUMA

62. P revention of Fat embolism syndrome Avoid increase in Intra-Medullary pressure Medullary channel depletion Venting the medullary channel Uncemented prosthesis

63. Facilities Necessary A full range of implants and instruments must be available It is the responsibility of the surgeon to ensure that his/her team knows what is going to happen. All those involved in the provision of surgical care for trauma patients must have regular training. Care of the patient does not stop once the surgery is completed. 1/18/2017 65

64. Normal Intra Medulary pressure - 30 – 50mm of Hg. Violent force in the bone – Intra Medulary pressure ↑many fold. Reaming increases Intra Medulary pressure up to 400-600 mm of Hg. MEDULLARY REAMING

65. NEGATIVE EFFECTS OF DELAYED FIXATION Prolonged immobilisation Pneumonia , bedsore, renal failure, inadequate nutrition, vascular abnormalities Poor results

66. TIMING OF SURGERY Day 1: Early total care- stable patients Day 2-5: A void surgery SIRS 2 nd hit is common Day 5-10: WINDOW OF OPPORTUNITY After Day 10- high infection rate.

67. 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. 1/18/2017 69

68. THANK YOU 1/18/2017 70