polytrauma.pdf

Polytrauma

1. POLYTRAUMA
Director &HOD
Prof.Dr. K.PRAKASAM
M.S.ORTHO,D.ORTHO,DSc(HON)
Moderator:DrHari
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.
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3. •Polytraumaneeds management by a team of surgeons
and physicians.
•Orthopaedicsurgeon is one of the team member of
trauma unit.
•Orthopaedicinjuries are generally not life-threatening
unless they result in significant hemodynamic instability.

4. •World wide No.1cause 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
•Polytraumais not a synonym of multiple fractures.
•Multiple fractures are purely orthopaedicproblem as
there is involvement of skeletal system
•While in polytraumathere 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-salvagabledeaths.

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

13. Advanced Trauma Life
Support(ATLS)
Four inter related stages
1.Rapid primary survey with simultaneous
resuscitation
2.Detailed secondary survey
3.Constant re-evaluation
4.Initiation of definitive care
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14. PRE-HOSPITAL PHASE
BASIC EMERGENCY MEDICAL TECHNICIAN
SKILLS
1.Maintenance of Airway ( endotrachealintubation)
2.Cardiopulmonary resuscitation
3.Fluid replacement with isotonic solution
4.Reduction and splintageof fractures
5.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
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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
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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
•AmbuBag
–Protection of the spineis very important while giving
airway maintanence.
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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 splintagecan be
applied.

25. Maintenance of circulation
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•I.V. Fluids one above and one below the
diaphragm
(Crystaloidsand 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.
-Resuscitatedwith a crystalloid, butsome may
requireblood 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 pressureshould 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,negligibleurine output.
•Consider2-3 units of FFPand a six pack of platelets
forevery 5 literof 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
oximeteror ABG
Incidence of Acute
Respiratory Distress
Severe chest injury →only life
savingprocedures

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 in 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 Score.

36. MANAGEMENT OF LIFE
THREATENING ORTHOPAEDIC
INJURIES

37. ZERO HOUR FIXATION
•Allpolytraumapatientswithinjuriesofotherorganslike
spleen,Liver,Kidney
•Majorbloodvesseltear
•Depressedskullfractures
•Pelvicfractures

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 polytraumapatient
•Can lead to life threatening hemorrahge–50% mortality
•Urethral injury –transurethral or suprapubiccatheter 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.

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47. PELVIC PACKING
•Done during laparotomy.
•In uncontrolled pelvic bleeding associated with abdominal
injuries .
•During packing always stabilisethe pelvis with external
fixators.

48. 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,internalpudendal, inferior gluteal, obturator.

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

50. “DAMAGE CONTROL
ORTHOPAEDICS”

51. 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

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

53. THE ‘SECOND HIT’ (2-5 DAYS)
•Severe trauma can result in a life threatening inflammatory
response (SIRS)
Threshold for
fatal
inflammatory
response
DEATH: from multiorganfailure 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

54. THE ‘SECOND HIT’ (2-5 DAYS)
•Severe trauma can result in a life threatening inflammatory
response (SIRS)
Threshold for
fatal
inflammatory
response
DEATH: from multiorganfailure 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

55. Patients For Damage Control
Surgery
•Stable
•Borderline
•Unstable
•Extreme

56. Damage Control Surgery Patients
STABLE No life threatening injuries,
haemodynamicallystable
Earlytotal care
BORDERLINEInitially respond to resuscitation
but can detoriate
Waitfor
improvement
UNSTABLE Remain hemodynamically
unstable despite initial
resuscitation
Damage control
surgery
EXTREME Close to death uncontrollable
blood loss
Damage control
surgery or ITU

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

58. 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

59. 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
mobilisationand prevention of thromboembolism.

60. Priorities in surgical management of
musculoskeletal injury
–Save life
–Save limb
–Save joints
–Restore function
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61. PRIORITIES IN FRACTURE CARE
•Pelvis
•Spine
•Femur
•Tibia
•Upper extremity

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

63. •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

64. Prevention of Fat embolism syndrome
•Avoid increase in Intra-Medullary pressure
•Medullarychannel depletion
•Venting the medullary channel
•Uncementedprosthesis

65. Facilities Necessary
•Afullrangeofimplantsandinstrumentsmustbe
available
•Itistheresponsibilityofthesurgeontoensurethat
his/herteamknowswhatisgoingtohappen.
•Allthoseinvolvedintheprovisionofsurgicalcarefor
traumapatientsmusthaveregulartraining.
•Careofthepatientdoesnotstoponcethesurgeryis
completed.
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66. •Normal Intra Medularypressure -30 –50mm of Hg.
•Violent force in the bone –Intra Medularypressure
↑many fold.
•Reaming increases Intra Medularypressure up to 400-
600 mm of Hg.
MEDULLARY REAMING

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

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

69. SUMMARY
•Polytraumamustbeconsideredasasystemicsurgical
disease
•Primaryobjectiveissurvivalofpatients
•Earlyfixationofmajorfractures–performedwithright
concepthasprovedtobeanimportanttooltoobtainthis
primaryobjective.
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70. THANK YOU
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