polytrauma ATLS final orthopaedics. .pptx

Polytrauma management and trauma scores

1. POLYTRAUMA+ATLS PROTOCOL PRESENTER : DR. JAINAM SALOT

2. DEFINATION TWO INJURIES THAT ARE GREATER OR EQUAL TO 3 ON AIS AND ONE OR MORE ADDITIONAL DIAGNOSES HYPOTENSION(SBP<90mmhg) UNCONSCIOUSNESS (GCS<8) ACIDOSIS(BASE DEFICIT<6) COAGULOPATHY (INR>1.4) AGE(>70 yrs)

3. Abbreviated injury scale(AIS) AIS is an anatomical scoring system first introduced in 1969

4. Injury severity score(ISS) The ISS score takes values from 0 to 75 . If an injury is assigned an AIS of 6 ( unsurvivable injury), the ISS score is automatically assigned to 75

5. NEW INJURY SEVERITY SCORE SUM OF SQUARE OF 3 MOST SEVERE INJURIES , REGARDLESS OF BODY REGION INJURED Eg - SPLEEN & LIVER INJURIES

6. HISTORY YEAR IDEOLOGY 1950’S Polytrauma patient is too sick for surgery. No surgical management. Splints and tractions. 1980’s Studies shows that early & definitive stabilization of Long bone fractures dramatically reduces fat embolism syndrome, pulmonary failure(ARDS) MODS Postoperative complications.

7. HISTORY YEAR IDEOLOGY 1980’S There is a beneficial effect of early stabilization of fractures. Patients were able to mobilize early and were discharged from hospital sooner ,avoiding the complications associated with prolonged bed rest. Concept of “EARLY TOTAL CARE (ETC)” was developed. Early total care (ETC): a concept implying the primary definitive management of all major injuries within 24 hours after trauma.

8. HISTORY YEAR IDEOLOGY EARLY 1990’s Outcome after ETC-increases incidence of ARDS and MOF. Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications. These complications developed mainly in pts with severe chest injuries, severe hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma. This led to the conclusion that the method of stabilisation and the timing of surgery may have played a major role in the development of such complications.

9. PATHOPHYSIOLOGY Traumatic injury leads to systemic inflammation(systemic inflammatory response syndrome) followed by a period of recovery mediated by a counter regulatory anti-inflammatory response. Within this inflammatory process, there is a fine balance between the inflammation and the potential for the process to cause and aggravate tissue injury leading to ARDS and MODS

10. PATHOPHYSIOLOGY

11. Damage Control Orthopedics To do as little As possible but sufficient enough to save Pt’s Life 4 phases Acute phase – Life saving procedures 2 nd phase – control of hemorrhage Temporary stabilization of long bone fractures Soft tissue injury maintain 3 rd phase – monitoring period in ICU 4 th phase – definitive fracture fixation

12. DCO EMERGENCY PROCEDURES ARE DONE ANYTIME 1 ST 2 DAYS – MANAGE BONY INJURIES BY UL – SPLINTS LL BELOW KNEE – SPLINT FEMUR – EX-FIX PELVIS - EXFIX

13. DEFINITIONS • Stable patients have no immediately life-threatening injuries and respond to initial therapy. • Borderline patients have stabilized in response to initial resuscitative attempts but sustained injuries that put them at risk of rapid deterioration . • Unstable patients remain hemodynamically unstable despite initial intervention and are at high risk for clinical complications. • Patients in extremis have ongoing uncontrolled blood loss despite resuscitation and may die if blood loss is not immediately stopped.

14. ADVANTAGES OF DCO Limits 2 nd hit Definative planning of polytrauma pt Shorter ICU stays Reduces MODS/ARDS Early rehab DISADVANTAGES OF DCO All pt termed borderline Use exfix everywhere

15. EARLY APPROPRIATE CARE ETC when pt has been resuscitated If following parameters come to normalcy within 36 HRS , go for definitive fixation of Fractures of Axial skeleton , otherwise DCO Lactate <4 Ph>7.25 BE <5.5

16. ATLS (ADVANCED TRAUMA LIFE SUPPORT)

17. INTRODUCTION ATLS originates from 1976 when James Styner an orthopedic surgeon crashed his light aircraft in rural Nebraska with his wife and 4 children onboard . His wife was killed instantly and 3 of his children sustained critical injuries. Having arrived at the nearest hospital, Styner found that, the care delivered to his family was inadequate and inappropriate and this stimulated him to initiate a trauma care program that transformed to ATLS

18. TRIMODAL DISTRIBUTION OF DEATH 3 PEAKS OF DEATH 1 st – seconds to minutes ( Apnea , Brain injury , spinal cord injury , Great vessel rupture ) 2 ND – minutes to several Hours ( Significant blood loss – ATLS prevents this ) 3 rd – days to week (MODS , SEPSIS)

19. PRINCIPLE OF ATLS TREAT FIRST THAT KILLS FIRST

20. Preparation Triage Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries Adjuncts to the primary survey and resuscitation Consideration of the need for patient transfer Secondary survey (head-to-toe evaluation and patient history) Adjuncts to the secondary survey Continued post resuscitation monitoring and reevaluation Definitive care

21. Preparation Preparation for trauma patients occurs in two different clinical settings: in the field and in the hospital. First during the prehospital phase , events are coordinated with the clinicians at the receiving hospital. Second, during the hospital phase , preparations are made to facilitate rapid trauma patient resuscitation

22. Prehospital Phase During the prehospital phase, personnel emphasize A irway maintenance C ontrol of external bleeding and shock, I mmobilization of the patient, I mmediate transport to the closest appropriate facility, preferably a verified trauma center

23. HOSPITAL PHASE

24. TRIAGE Triage is a system of medical sorting ,originating from the Napoleonic battle fields to identify casualties in an order of priority for evacuation and treatment. In trauma management ,triage is used when the number of causalities is greater than can be managed simultaneously by the medical personnel available.

25. Red (urgent) —Lifesaving interventions (airway, breathing, circulation) are required. Yellow (delayed) —Immediate lifesaving interventions are not required. Green (minor) —Minimal or no medical care is needed, or the patient has psychogenic casualties. Black —Patient is deceased

26. PRIMARY SURVEY WITH SIMALTANEOUS RESUSCITATION The primary survey encompasses the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence: A irway maintenance with restriction of cervical spine motion B reathing and ventilation C irculation with hemorrhage control D isability(assessment of neurologic status) E xposure/Environmental control

27. QUICK ASSESSMENT ASK NAME IF HE RESPONDS – ABCD IS INTACT

28. AIRWAY MAINTAINANCE WITH RESTRICTION OF CERVICAL SPINE MOTION

29. AIRWAY ASSESMENT Inspecting foreign bodies Identifying facial , mandibular , tracheal fractures Stabilize the cervical spine immediately Cervical collar ,head supports and strapping During manual in line immobilization , care should be take no to hyperextend the cervical spine

30. WHAT TO LOOK FOR Agitation,aggression,anxiety – suggest hypoxia Obtunded conscious levels – suggests hypercarbia Cyanosis – bluish discoloration of nail beds and lips caused by hypoxemia due to inadequate oxygenation Sweating : increases autonomic activity Use of accessory muscles of ventilation Tracheal tug and intercostal retraction –caused by exaggerated intra thoracic pressure swings

31. LISTEN: Noisy breathing : collapsing pharyngeal muscles , obstructed airway Stridor Hoarse voice Absence of noise FEEL: Palpation of trachea in the suprasternal notch will detect the deviation associated with a tension pneumothorax

32. CAUSES FOR AIRWAY OBSTRUCTION HEAD INJURY MAXILLOFACIAL TRAUMA NECK TRAUMA LARYNGEAL TRAUMA INHALATIONAL BURNS

33. Chin-Lift Maneuver The chin-lift maneuver is performed by placing the fingers of one hand under the mandible and then gently lifting it upward to bring the chin anterior. With the thumb of the same hand, lightly depress the lower lip to open the mouth The Chin-Lift Maneuver to Establish an Airway. Providers should avoid hyperextending the neck when using this maneuver.

34. JAW THRUST To perform a jaw thrust maneuver, grasp the angles of the mandibles with a hand on each side and then displace the mandible forward .When used with the facemask of a bag-mask device, this maneuver can result in a good seal and adequate ventilation. As in the chin-lift maneuver, be careful not to extend the patient’s neck.

35. Nasopharyngeal Airway Nasopharyngeal airways are inserted in one nostril and passed gently into the posterior oropharynx. They should be well lubricated and inserted into the nostril that appears to be unobstructed. If obstruction is encountered during introduction of the airway, stop and try the other nostril

36. Oropharyngeal Airway Oral airways are inserted into the mouth behind the tongue. The preferred technique is to insert the oral airway upside down, with its curved part directed upward, until it touches the soft palate. At that point, rotate the device 180 degrees, so the curve faces downward, and slip it into place over the tongue

37. Extraglottic and Supraglottic Devices Example of a laryngeal mask airway supraglottic airway. should be located into the upper esophageal opening.

38. Example of a laryngeal tube airway. Example of a multilumen esophageal airway

39. DEFINITIVE AIRWAY A definitive airway is defined as a tube placed in the trachea with the cuff inflated below the vocal cords. The tube connected to a form of oxygen-enriched assisted ventilation, and the airway secured in place with an appropriate stabilizing method. Definitive airways include endotracheal intubation and surgical airways Needle cricothroidotomy surgical cricothyroidotomy A definitive airway should be placed early after the patient has been ventilated with oxygen-enriched air, to prevent prolonged periods of apnea .

40. INDICATIONS FOR DEFINITIVE AIRWAY GCS<8 UNCONSCIOUS pt NON PURPOSEFUL MOTOR MOVEMENTS IF IN DOUBT

41. Palpate the thyroid notch, cricothyroid interval, and sternal notch for orientation. Make a skin incision over the cricothyroid membrane and carefully incise the membrane transversely. Insert a hemostat or scalpel handle into the incision and rotate it 90 degrees to open the airway. Insert a properly sized, cuffed endotracheal tube or tracheostomy tube into the cricothyroid membrane incision, directing the tube distally into the trachea .

42. Breathing and Ventilation The patient's chest neck and abdomen are fully exposed to allow assessment of chest. Start o2 inhalation to all patients of polytrauma

43. Inspection - Respiratory rate : tachyphoea is indicative of hypoxia Shallow , gasping or labored breathing – suggest respiratory failure Cyanosis – indicates hypoxia Plethora and petechiae – suggests asphyxia and chest crushing Paradoxical respiration : breathing with asynchrony between abdomen and chest –indicates respiratory failure or structural damage Unequal chest inflation – pneumothorax or flial chest Penetrating chest injuries : potential for pneumothorax Distended neck veins : increased venous pressure secondary to a tension pneumothorax or cardiac tamponade

44. Auscultation - Absence of breath sounds – indicates apnoea or tension pneumothorax Noisy breathing /ceptations/stridor/wheeze suggests partially obstructed airway, blood/secretions in the airway /tracheal or bronchial damage Reduced air entry – indicates a pneumothorax , hemothorax hemopneumothorax , flial chest

45. FEEL : Tracheal deviation : indicative of tension pneumothorax , shifting of mediastinum Tenderness : Rib fracture Crepitus : Fractured ribs Surgical emphysema (crackling and popping bubble wrap crepitus feel to subcutaneous soft tissue on palpation ,due to presence of air forced into tissue under pressure : tension pneumothorax ,ruptured bronchi, fractured larynx

46. Tension Pneumothorax Open Pneumothorax Massive Hemothorax Cardiac Tamponade Flail Chest Disruption of tracheobronchial tree IMMEDIATE LIFE THREATENING CHEST INJURIES

47. Tension Pneumothorax Tension pneumothorax develops when a “one-way valve” air leak occurs from the lung or through the chest wall . Air is forced into the pleural space with no means of escape, eventually collapsing the affected lung. The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung.

48. Treatment : Needle decompression using 14 g-16 g needle: 2 nd intercostal space mid clavicular line Tube thoracostomy : 4 th ,5 th 6th intercos tal space anterior axillary line

49. OPEN PNEUMOTHROAX Large injuries to the chest wall that remain open can result in an open pneumothorax, also known as a sucking chest wound

50. Immediate Management: Promptly close the defect with a sterile occlusive dressing that is large enough to overlap the wound’s edges. Tape it securely on three sides to provide a flutter-valve effect.

51. FLIAL CHEST This condition usually results from trauma associated with multiple rib fractures (i.e. two or more adjacent ribs fractured in two or more places), although it can also occur when there is a costochondral separation of a single rib from the Thorax Definitive treatment of flail chest and pulmonary contusion involves ensuring adequate oxygenation, administering fluids judiciously, and providing analgesia to improve ventilation

52. MASSIVE HAEMOTHORAX The accumulation of >1500 ml of blood in one side of the chest with a massive hemothorax can significantly compromise respiratory efforts by compressing the lung and preventing adequate oxygenation and ventilation

53. CIRCULATION AND HAEMORRHAGE Hemorrhage is the predominant cause of preventable deaths after injury Look for blood volume , cardiac output , bleeding aspects

54. CIRCULATION IMPAIRMENT IN CIRCULATION CAN LEAD TO SHOCK SO LOOK FOR SIGNS OF SHOCK i.e. SKIN COLOUR (PALLOR) Pulse variation HYPOTENSION TACHYCARDIA LEVEL OF CONSCIOUSNESS DIMINISHED URINE OUTPUT

55. CONTROL OF HEMORRHAGE : External bleed Definitive control of hemorrhage and restoration of adequate circulating volume are the goals of treating hemorrhagic shock APPLY DIRECT PRESSURE Tourniquet ACCESS THE NEED FOR SURGICAL INTERVENTION

56. Internal bleed THORAX – CHEST COMPRESSION TEST ABDOMEN PELVIS – PELVIC COMPRESSION TEST ( give pelvic binder ) Long Bones - Splinting

57. FLUID REPLACEMENT THERAPY DOUBLE I/V LINES SHOULD BE MAINTAINED FOR FLUID REPLACEMENT Shock associated with injury is most often hypovolemic in origin. In such cases, initiate IV fluid therapy with crystalloids. All IV solutions should be warmed either by storage in a warm environment (i.e., 37 ° C to 40 ° C, or 98.6 ° F to 104 ° F) or administered through fluid warming devices. ADULTS SHOULD BE GIVEN 2 L ITERS BOLUS FLUID (PREFFERED FLUID IS RINGER LACTATE ) Response to initial fluid challenge: Immediate & sustained return of vital signs. Transient response with later deterioration No Improvement

58. CLASSIFICATION I V Fluids Blood and Products Non blood I V Fluids Crystalloids Glucose Containing Ele c trol y te solutions Mixed Colloids Proteinous Non proteinous Gelatins Haemaccel Gelofusin Albumin 20% & 5% Starch Dextrans HES PentaStarch Tetrastarch

59. ATLS CLASSIFICATION OF HYPOVELMIC SCHOCK

60. Massive fluid resuscitation will lead to dilution of platelets and clotting factors, as well as the adverse effect of hypothermia on platelet aggregation and the clotting cascade, contributes to coagulopathy in injured patients. Some jurisdictions administer tranexamic acid in the prehospital setting to severely injured patients in response to recent studies that demonstrated improved survival when this drug is administered within 3 hours of injury. The first dose is usually given over 10 minutes and is administered in the field; the follow-up dose of 1 gram is given over 8 hours. Blood Transfusion Protocol – 1:1:1 ( 1 FFP:1 packed cell:1 concentrated Platelets )

61. BLOOD TRANSFUSION FULLY CROSS-MATCHED PRBC PREFERABLE TYPE O PRBC AB PLASMA MASSIVE TRANSFUSION >10 PRBC IN 24 HRS >4 PRBC IN 1 HR

62. DISABILITY CHECK THE LEVEL OF CONSCIOUSNESS ( AVPU/GCS ) A: ALERT V: RESPONDS TO VOCAL STIMULI P: RESPONDS TO PAINFUL STIMULI U: UNRESPONSIVE TO ALL STIMULI CHECK PUPIL LARY REFLEXES QUICK DETERMINATION OF SPINAL CORD INJURY LEVEL

63. EXPOSURE / ENVIRONMENTAL CONTROL COMPLETELY UNDRESS TO LOOK FOR MISSED INJURIES WARM BLANKETS / EXTERNAL WARMER

64. ADJUNCT TO THE PRIMARY SURVEY WITH RESUSCIATION Physiologic parameters such as pulse rate, blood pressure, pulse pressure, ventilatory rate, ABG levels, body temperature, and urinary output are assessable measures that reflect the adequacy of resuscitation. ECG Pulse Oximetry ABG Urinary Catheters FAST X-ray Examinations and Diagnostic Studies

65. CONSIDER TRANSFER AFTER PRIMARY SURVEY IS COMPLETED , PT IF REQUIRES TRANSFER TO HIGHER CENTRE IS DONE AT THIS STAGE.

66. SECONDARY SURVEY

67. The secondary survey does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are under way, and improvement of the patient’s vital functions has been demonstrated. The secondary survey is a head-to-toe evaluation of the trauma patient—that is, a complete history and physical examination, including reassessment of all vital signs. Each region of the body is completely examined. The potential for missing an injury or failing to appreciate the significance of an injury is great, especially in an unresponsive or unstable patient.

68. PATIENT HISTORY SUCH AS (AMPLE) Allergies Medications currently used & Alcohol intake Past illnesses / Pregnancy Last meal Events / Environment related to the injury( Gaseus / Snake bite)

69. PHYSICAL EXAMINATION (head-toe) HEAD Maxillofacial Structures Cervical Spine and Neck Chest Abdomen and Pelvis Perineum, Rectum, Vagina Musculoskeletal System Neurological System

70. Atleast four people are needed for logrolling a patient to remove a spine board and/or examine the back. A. One person stands at the patient’s head to control the head and c-spine, and two are along the patient’s sides to control the body and extremities. B. As the patient is rolled, three people maintain alignment of the spine while C. T he fourth person removes the board and examines the back. D. Once the board is removed, three people return the patient to the supine position while maintaining alignment of the spine.

71. THANK YOU