polytrauma notes for reference and test .pptx

High yield notes on polytrauma

1. POLYTRAUMA Presented By, Athullya C MSc Medical Surgical Nursing Govt. College of Nursing, Kottayam

2. Definition: Polytrauma is a clinical condition/state following injury to the body leading to profound metabolic changes involving multisystem. Polytrauma is a significant injury in at least 2 of the following 6 body regions: - Head, neck and cervical spine - Face - Chest and thoracic spine - Abdomen and lumbar spine - Limbs and bony pelvis - Skin

3. Criteria of Polytrauma: 2 major system injury + One major limb injury One major system injury + 2 major limb injury One major system injury + One open grade 3 skeletal injury Unstable pelvic fracture with associated visceral injury

4. Injury severity score (ISS): An established medical score to assess trauma severity. Correlates with mortality, morbidity and hospitalization time after trauma. Scoring system based on anatomic criteria.

5. Six ISS body regions to consider, to calculate ISS: 1. Head and neck including cervical spine 2. Face including facial skeletal, nose, mouth, eyes and ears 3. Chest – Thoracic spine and diaphragm 4. Abdomen and pelvic contents – Abdominal organs and lumbar spine 5.Extremities or pelvic girdle 6. External - Skin

6. ISS calculation based on AIS grading AIS score Injury No injury 1 Minor injury 2 Moderate injury 3 Severe injury – not life threatening 4 Severe injury – life threatening; survival probable 5 Severe injury – critical and survival uncertain 6 Maximal injury – possible fatal Score ranges from 1-75

7. Revised trauma score (RTS): Most widely used pre-hospital field triage tool. It includes: - Glasgow coma scale (GCS) - Systolic BP (SBP) - Respiratory rate (RR) Lower score indicates higher severity. RTS < 4, proposed for transfer of the patients to trauma center.

8. The revised trauma score (RTS) GCS SBP RR RTS value 13-15 >89 10-29 4 9-12 76-89 >29 3 6-8 50-75 6-9 2 4-5 1-49 1-5 1 3

9. Systemic inflammatory response syndrome score (SIRS Score): It is a generalized response to trauma that likely has a genetic predisposition. It is associated with conditions like: - DIC - ARDS - Renal failure - Multi system organ failure - Shock

10. Variables of SIRS scoring are: - HR > 90 b/m - WBC count < 4000 cells/mm3 - RR > 20 b/m - Temperature < 36 or 38 degree Each variable is given 1 point and a score of 2 or more is consistent with SIRS. To score, 2 or more of the variables should be present for the patient.

11. Trauma score – injury severity score (TRISS) : It determines the probability of survival (Ps) of the trauma patient. Variables of TRISS are : ISS, RTS and patients age (AI-Age index) Age index (AI) is : - 0  If patient is below 54 years of age - 1  If patient is 55 years and over Ps =   where , b = b0 + b1 (RTS) + b2 (ISS) + b3 (AI)

12. Co-efficient value Blunt Penetrating b0 - 0.4499 - 2.5355 b1 0.8085 0.9934 b2 - 0.0835 - 0.0651 b3 - 1.7430 - 1.1360 If the score is less than 15, the blunt coefficient are used regardless of mechanism. TRISS calculator

13. Incidence: Polytrauma is the 3 rd most common cause of death in all age group. Victims chances of survival are greatest, if patient receives definite OR care within 1 hr after a severe injury. Golden hour = 80% of trauma death occurs in 1 st hr (60 min) after injury Platinum 10 minute = Only 10 min of golden hour is used for on-screen care

14. 1 st Peak - Major neurological / vascular injury 2 nd Peak - Intracranial hematoma, major thoracic or abdominal injury 3 rd Peak - Sepsis and multiple organ failure

15. 1 st Peak Immediate death (0-1 hr) Accounts 50% of death. Due to major neurological/vascular injury (un-survivable injuries). Die-on-scene case Eg : - Severe head injury - Brain stem injury - High cord injury - Heart and major vessel injury - Massive blood loss

16. 2 nd Peak Early death (1-3 hrs). Accounts 30% of deaths. Occurs during golden hour. Due to ICH, major thoracic and abdominal injury. Primary focus of intervention for the ATLS methodology. Eg : - Intracranial bleed - Abdominal bleeding - Pelvic bleeding - Multiple limb injury

17. 3 rd Peak Late death (1-6 weeks). Accounts 20% of deaths. Occurs after days or weeks. Due to complications of sepsis and multi-organ failure.

18. Mechanisms of Polytrauma: Penetrating Blunt Blast Burns – Thermal / Chemical Others – Crush / Barotrauma

19. Etiology of Polytrauma: RTA Fall from height (blunt / penetrating) Assault Airplane crashes Train derailment Blast Thermal and chemical injury Suicide / Homicide

20. Pathophysiology of Polytrauma: Primary insult - Trauma - Organ failure - Tissue injury - Fracture Secondary insult - Ischemia - Surgery - Interventional load Hyperinflammation SIRS & MOF Hypo inflammation CARS MARS

21. Signs and symptoms of Polytrauma: Direct signs and symptoms Pain Severe bleeding Others Loss of memory Light headedness Headache Difficulty concentration Impaired decision making skills

22. PARADOXICAL BREATHING

23. Types of shock in Polytrauma : Haemorrhagic shock Neurogenic shock Hypoxic shock Septic shock

24. Management of Polytrauma

25. I. Advanced trauma life support (ATLS): COMPONENTS - Treat first lethal injury - Reassessment - Treat again / Transfer AIMS - Gain access to victim - Smooth transfer APPROACHES - Scoop & Run policy - Stay & Play policy

26. Algorithm - ATLS Injury Definitive care Primary survey Resuscitation Re-evaluation Transfer Re-evaluation Secondary survey

27. Triage Start Triage algorithm: - Ability to walk - Airway - Respiratory rate - Pulse rate / Capillary return Two approaches: - Triage sieve - Triage sort

28. TRIAGE Triage category Definition Colour Treatment Example Category 1 Critical & life threatening Red Immediate Tension pneumothorax Category 2 Urgent – but can wait 30 min Yellow Urgent Femur fracture Category 3 Minor – less serious injury Green Delayed Sprained ankle Category 4 Dead / not expected to survive White Or Black - -

29. Triage guidelines Protect yourself, casualty and other road users. Park vehicle safely and set hazard signal. Do not cross a busy motor-way to reach casualty. Set warning triangles/ lights. Switch off ignition of damaged vehicle. Check all casualties and save.

30. Triage : On-scene priorities Stay safe Obtain access Protect cervical spine Free the airway Ensure ventilation Arrest haemorrhage Combat shock Control pain Splint fractures Transfer to hospital

31. Call –Out criteria Penetrating injuries 2 or more proximal bone fracture Flail chest & Pulmonary contusion Evidence of high energy trauma Management at hospital Trauma team Trauma code 4 Doctors 5 Nurses 1 Radiographer Fall from height > 6 feet Change in velocity of 32 kmph 35 cm displacement of side wall of car Ejection of patient Roll over Death of another person in same car Blast injuries

32. TRAUMA TEAM

33. Assessment approach to injured patient a) ATLS – Primary survey A - Airway & securing cervical spine B - Breathing C - Circulation & haemorrhage D - Dysfunction of CNS E - Exposure INVESTIGATIONS X-Ray : Chest, pelvis CBC ECG CT Scan

34. A – Airway & cervical spine Open airway using “chin-lift” or “jaw thrust”. Suction Oxygen therapy Always assume patient has cervical spine injury. Assist airway and breathing – ET tube, Cricothyroidotomy or tracheostomy. INDICATION FOR INTUBATION – TRAUMA Bleeding & hypovolemic shock Hypoxia Low GCS Severe head injury

35. B – Breathing & Ventilation Look for exposure Inspection Palpation Movement Auscultation Hunt out & treat 5 life threatening thoracic conditions Tension pneumothorax Massive pneumothorax/ haemothorax Open pneumothorax Flail segment Cardiac tamponade

36. C – Circulation & Haemorrhage control Adults  If hypotensive : fluid therapy with 2L of crystalloids.  In cardiac arrest : fluid therapy with 1L of crystalloids.  As soon as possible blood transfusion. Children  20ml/kg of body weight fluid therapy. Assess for bleeding, shock and control external haemorrhage. Assess pulse, capillary return and state of neck veins. Identify exsanguinating haemorrhage & apply direct pressure.

37. Use “FAST” to identify body cavity haemorrhage. Place 2 large bore cannula & draw blood samples for diagnostic tests. Attach patient to ECG monitor for tachycardia. Assessment of blood loss: Fluid resuscitation External / Obvious Internal / Covert : - Chest : 2-4 units - Abdomen : - Pelvis : 2-6 units - Limbs (fracture) : UL  1-4 Units : LL  2-4 Units

38. Lethal triad of death:

39. Current concepts of balanced resuscitation: Fluid replacement in balanced resuscitation Initial fluid replacement with up to 2L of crystalloid to achieve “Permissive hypotension”. Permissive hypotension is the use of restrictive fluid therapy. b) Haemostatic resuscitation Early blood vs HBOC transfusion decreases MODS. Infuse packed RBC, FFP & platelet in ratio 1:1:1. Use cryoprecipitate, tranexamic acid & recombinant factor VIIa. Store blood of <2weeks to prevent TRALI & MODS.

40. Response to initial fluid challenge < 20% blood loss & bleeding stops spontaneously Immediate response & sustained return of vital signs. Bleeding within body cavity & surgical intervention is required Transient response with later deterioration. >40% of blood loss requiring immediate surgery & continued IV fluids is detrimental No improvement or response.

41. D – Disability/Dysfunction Assess LOC using “AVPU”: A V P U

42. Assess pupil size, equality & responsiveness. Assess GCS:

43. E – Exposure Fully undress patient. Avoid hypothermia. HYPOTHERMIA PREVENTIVE STRATEGIES Limit casualty exposure. Warm IV fluid & blood products before transfusion. Use forced air warming devices before & after surgery. Use carbon polymer heating mattress.

44. II. ATLS – Secondary survey Comprises head-to-toe examination of the stable patient. Requires detailed history – “AMPLE” Thorough examination. Continuous vital signs monitoring. Detailed radiographic procedures – CT, MRI, USG. Allergies Medications Past medical history Last meal Events surrounding injury

45. Examination : a) Head & ENT : GCS score Pupil size & reaction Plantar response Nose fracture & septal hematoma Signs of rhinorrhoea & otorrhoea Signs of basal skull fracture: - Racoon eye - CSF rhinorrhoea & otorrhoea - Battles sign - Hemotympanum - Profuse bleeding from nose & ears

46. b) Neck : Subcutaneous emphysema Cervical spine fractures (C1, C2, C7) Penetrating neck injuries c) Thorax : Pulmonary complications Myocardial contusion Aortic tear Diaphragmatic tear Oesophageal tear Tracheobronchial tear

47. d) Pelvis : Clinical assessment – Xray Stabilize pelvis with fixator or clamps, Check for urethral injury - High up prostate in PR - Blood in meatus - Perineal hematoma Do “Ascending urethrogram & Suprapubic cystostomy”, if pelvic fracture is suspected. If there is no suspected pelvic fracture, do “Trial catheter with gentle manipulation & Fine catheter with lots of lubricants”.

48. e) Abdomen : Insert NGT & urinary catheter for diagnosis and treatment. Perform rectal examination. Wound coverage Pack eviscerated bowels with warm wet mops. For rigid and distended abdomen, do: - USG - 4 quadrant tap - Diagnostic peritoneal lavage - Laparoscopic examination In case of any deterioration, consider rapid surgical exploration.

49. f) Spinal cord: Thorough sensory and motor examination. Prevent further damage in unstable fracture. Log-rolling for full neurological examination. Use a long spine board for transportation. g) Extremities : Full assessment of limbs for injury. Look for distal pulse and neuro status. Carefully look for skin and soft tissue viability. Look for impending compartment syndrome.

50. Common fractures in Polytrauma: Minor Moderate  Open fracture of digits  Un-displaced long bone fracture or pelvic fracture Serious  Closed long bone fractures  Multiple hand/foot fractures Severe  Life threatening fractures  Long bone fracture  Pelvic fracture with displacement  Dislocation of major joints  Multiple amputation of digits  Amputation of limbs  Multiple closed long bone fracture

51. Complications : ARDS Tetanus Fat embolism DIC Compartment /Crush syndrome MSOF

52. Innovative treatment modalities: Tourniquets Newer external devices for haemorrhage control Negative pressure wound therapy (NPWT)

53. COMBACT READY CLAMP XSTAT

54. NEGATIVE PRESSURE WOUND THERAPY

55. THANK YOU !