Polytrauma

polytrauma dilemma

1. The Dilemma in Approach to Polytrauma Management Dr. SHUBHANSHU ( Orthopedic Surgeon)

2. Overview Challenges Components of Organised Trauma System ATLS: Key Components and ATLS: recent changes in guidelines Shock In The Polytraumatized Patient Risk Management: Missed Injuries Special Patient Population Return patient near pre-injury status

3. Introduction: Challenges C ommon injuries C ommon causes of mortality I nitial management Definitive Management A pproach to improve the outcome vs ETC Trauma courses and M ock drills Trimodal pattern of death Requires a well developed and standardized management system or protocol, the Advanced Trauma Life Support (ATLS). Methodology Trunkey DD. Trauma. Sci Am 1983.

4. Definition Polytrauma : Two or more significant injury to two or more organ system Abbreviated Injury score(AIS)>2 Injury Severity Score (ISS) > 15 Definition also includes: concurrent injury to two or more body parts or systems that results in cognitive, physical, psychological or other psychosocial impairment. Dobscha et al, Washington (DC): Department of Veterans Affairs (US); 2008 Sep. Sequential systemic reactions that may lead to: dysfunction or failure of uninjured organs and vital systems

5. Challenges Real Challenge: RTA affects young productive population most Special Patient Populations Polytrauma in pregnancy: Imaging, Positioning, priority Elderly/ Paediatric Fear of fat embolism syndrome /ARDS/MODS/Sepsis/DVT/ Acute PE

6. Challenges in Emergency Sensitive patients: team work and counselling Overcrowding : Train more and more co-workers Urgency of care: Mock drill at regular intervals Physical and psychological distress, Long wait before being seen by a doctor or being transferred

7. Components Of Organized Trauma Care Systems. Leadership Prehospital and in-hospital triage Designated and accredited trauma care facilities Human resources (planning, administrative and clinical teamwork) Good communication (at all levels of the trauma system) Data collection

8. Polytrauma Pathophysiology SIRS/CARS. immunoinflammatory reactions leading to an increased vascular permeability/ Toxic mediators/ Elastase enz. Immune paralysis The Silver Day : (posttraumatic therapeutic window of 24 h). Golden Hour Platinum ten Minutes

9. Decision making: Lactate/ Base deficit/ ABG Urine output Mortality predictors: Arterial haemoglobin oxygen saturation, DBP, GCS, crystalloid volume and presence of TBI are independent early mortality predictors Guilherme et al, Clinics. 2017;72(8) ISS, Ganga Hospital score

10. Key components of ATLS Team leader Solid framework Common language Hospital pre-alert/ Handover Primary survey: quickly identify and treat what kills people first Katrina Megget , March 2018 ABCDE: simultaneously or in sequence. AVPU/GCS Secondary Survey: AMPLE, Head to toe

11. Changes in ATLS Guidelines 10 th Ed. Close the tap

12. SHOCK The most common cause of preventable death following trauma. Lactate: Oxygen debt and tissue hypoperfusion Base deficit: indirect estimation of global tissue acidosis due to impaired perfusion.

13. Ongoing Bleeding: Management Close the tap( Immediate):—cABC is key keep the patient warm/ fluid / blood Mortality increased 6-fold in patients who received >15 L crystalloids ≤24 hours. Wessem et al, Trauma Surg Acute Care Open. 2020 Oct The CRASH-2 trial : Tranexamic acid , reduces transfusion requirements and mortality. Within 3 h of injury reduces one third of mortality. Roberts I. J Thromb Haemost. 2015 DCR: minimize blood loss, maximize tissue oxygenation, and optimize outcome”.

14. Risk Management: Missed Injuries

15. Suspected neurological injury: Spinal board with appropriate cervical spine precautions. Spinal injury: assessment and initial management NICE guideline 2016

16. Special Patient Population

17. Changes in ATLS Guidelines 10 th Ed.

18. A pproach to improve the outcome Trauma/Multidisciplinary team  Trauma nurses will also be on the front lines Upon arrival: Effective handover Methodological approach Timely intervention Communication to patient relatives Life > Limb [disabilities]

19. Priorities and Timing of Definitive care

20. PRISM Concept Of Management Of Polytrauma Giannoudis, P. V., Giannoudis, V. P., & Horwitz, D. S. (2017). Time to think outside the box: “Prompt-Individualised-Safe Management” (PR.I.S.M.) should prevail in patients with multiple injuries. Injury, 2017

21. ETC, DCO, EAC H.C. Pape et al. The American Journal of Surgery (2002)

22. When to Intervene ETC, DCO, EAC Old philosophy : The injured patient was “too sick to operate on” Early total care (ETC) : 1980s: Early definitive fixation of long bone fractures. In the unstable patient, long operations lead to a 'second hit’, worsened outcomes. Suggested early surgical stabilization consistently leads to shorter hospital stays, shorter ICU t stays. Dimar et al, SPINE Vol 35,2010 Damage control orthopaedics (DCO):2000: Stabilization, not definitive fixation. Early appropriate care (EAC): 2013: Focus on resuscitation rather than injury severity score. wikipedia.org/wiki/Early_appropriate_care

23. So Where we Stand Fracture fixation: Not during resuscitation but delayed until Full resuscitation Return to normal physiological parameters. Exception: Considers the fixation of unstable pelvic and spinal fractures as a part of resuscitation ETC and DCO are complementary to each other and used for different groups of patients.

24. Controversy: So Where we Stand EAC prescribes that definitive management of unstable axial skeleton and long bone fractures should only be undertaken within 36 hours if an adequate response to resuscitation has been demonstrated by: pH ≥7.25 Lactate ≤4 mmol/L Base excess > -5.5 mmol/L wikipedia.org/wiki/Early_appropriate_care

25. Dilemmas Ethical : Triage : Who shall live when not everyone can live Legal : Documentation and proper communication is lacking F irst aid: nearby clinics, vs multidisciplinary team.

26. Take Home Unstructured management: associated with avoidable death and disability. Act quickly and systematically: Time is essence Ethical and legal issues : Adhere to Guidelines Assuming every patient is Covid positive: Take precautions