Stabilization of polytrauma patient

Emergency Medicine, ATLS 10th update, Polytrauma

1. TRAUMA AND EMERGENCY Stabilization of Polytrauma patient: ATLS Guidelines Dr. Padmaja Pallavi (SR Trauma & Emergency) Dr. Vinay Kumar Singh (JR-1 Emergency Medicine)

2. Hypothetical Scenario 24 yr old male had motorbike accident with a tractor and was under the tractor wheels for 10 min On arrival in ED (transport time 10-15 min): Wearing a helmet, obvious facial injuries, injury marks on chest and abdomen, open femur fracture Helmeted, with cervical collar, on backboard Unresponsive, tolerating oro -pharyngeal airway Oxygen by venturi mask @15l/min Vomitus present in mask O/E :- noisy breathing, RR=40/min, shallow, SpO2=80% HR=140, BP=80/60,peripheries cold, No iv access What is the next step in management?

3. Initial assessment and management PRIMARY SURVEY Check “ABCDE” Frequent reassessment Life threatening injuries 10 second assessment SECONDARY SURVEY ‘AMPLE’ history Allergy Medications currently used Past illness, Pregnancy Last meal Events / Environment related to injury Detailed examination Head to toe Back and front Detailed work up

4. 6/2/2020 4 PRIMARY SURVEY (Initial assessment) “ABCDE”

5. A: Secure & Maintain Airway Patency with C-spine protection Signs of airway obstruction: (Noisy breathing, labored breathing, stridor , cyanosis) Maneuvers : In-line stabilization of C spine Check airway patency Clear airway: secretions, vomitus , blood, dentures Suction equipment, Suction catheters , l arge bore tonsil suction apparatus ( Yankauer ) Open airway: Chin lift (not head tilt) Jaw thrust Maintain airway patency: Oropharyngeal or nasopharyngeal airway 6/2/2020 5

6. AIRWAY & VENTILATORY MANAGEMENT

7. Open airway (maintain in-line stabilization) 6/2/2020 7 Jaw thrust ONLY C hin L ift

8. Maintain airway patency (maintain in-line stabilization) Oropharyngeal airway Nasopharyngeal airway 6/2/2020 8 Avoid nasopharyngeal airway /nasal intubation : Nasal/ cribriform plate fracture : CSF leaks: rhinorrhea , otorrhea Basilar skull fracture: Racoon eyes ( periorbital ecchymosis ) Battle sign ( retroauricular ecchymosis )

9. Definitive airway (maintain in-line stabilization) Endotracheal tube (oral or nasal) Airway secured with tape Oxygen enriched assisted ventilation 6/2/2020 9 EMERGENT URGENT Cardiac arrest Unconsciousness Respiratory failure Shock Facial burns with risk of airway loss Facial trauma with partial airway obstruction Apnea Loss of airway patency Inhalational burns with respiratory distress

10. AIRWAY (ATLS 10 TH Edition), a clinical update

11. NEEDLE CRICOTHYROIDOTOMY

12. SURGICAL CRICOTHYROIDOTOMY

13. TRACHEOSTOMY

14. Prevention of hypoxia - top priority Adequate gas exchange to maximize oxygenation and CO 2 elimination. Every injured patient should receive supplemental oxygen Face mask, Bag and mask, Definitive airway Detailed Examination of neck and chest to detect “life threatening events”. 6/2/2020 14 B: Breathing and ventilation

15. ASSESSMENT MANAGEMENT Airway obstruction Noisy breathing, labored breathing, stridor , cyanosis Oropharyngeal or nasopharyngeal airway Definitive airway Tension pneumothorax Tracheal deviation away Distended neck veins Tympany Absent/↓ sed breath sounds Needle decompression Tube thoracostomy Open pneumothorax Open wound Tympany ↓ sed breath sounds D r essing on 3sides of wound : Valve effect Tube thoracostomy Flail chest/ Tracheo -bronchial Tree Injury Pulmonary contusion Rib fract u re Labored breathing Cyanosis Paradoxical breathing Analgesia Oxygenation J u dicio u s fl u ids Massive haemothorax Tracheal deviation Flat neck veins Dull note Absent/↓ sed breath sounds Venous access Volume replacement Tube thoracostomy Thoracotomy 6/2/2020 16

16. E-FAST (ATLS 10 Th Edition), a clinical update

17. NEEDLE DECOMPRESSION

18. 6/2/2020 19 Tension pneumothorax Open pneumothorax Needle thoracentesis Tube thoracostomy 36Fr Dressing on 3sides of wound Tube thoracostomy

19. 6/2/2020 20 Tube thoracostomy Thoracotomy : >1500 ml blood immediately evacuated >200ml/hr blood in drains for 2-4 hrs Analgesia Oxygenation and ventilation Judicious fluids * Flail Chest/ Tracheobronchial Injury *Pulmonary Contusion Massive hemothorax

20. TRAUMATIC CARDIAC ARREST

21. C: Circulation with hemorrhage control Pulse, skin color, peripheries, BP Hemorrhagic Shock: Most common type of shock in trauma Definitive control of hemorrhage Step1. Direct pressure on wound, tourniquet, splint Step2. Pelvic stabilization Step3. Angio-embolization Step4. Surgical ligation Aggressive fluid resuscitation Step1. Two large calibre intravenous access Step2. Samples for blood grouping and cross-match, appropriate labs, toxicology studies Step3. Prevent hypothermia - Warm fluids Step4. PRBCS Look for occult hemorrhage 6/2/2020 23 STOP BLEEDING‼

22. SAVE A LIFE

23. Initial Assessment(ATLS 10 TH Edition), a clinical update

24. Signs and Symptoms of Haemorrhage by class (ATLS 10 TH Edition)

25. Response to initial fluid resuscitation (ATLS Protocol) 1000-2000 ml isotonic crystalloids in adults; 20ml/kg bolus in children RAPID RESPONSE TRANSIENT RESPONSE MINIMAL or NO RESPONSE Reason for shock 10-20% blood loss 20-40% blood loss Ongoing loss Inadequate r esuscitation Non-hemorrhagic shock >40% loss Non-hemorrhagic shock Need for more crystalloid Low High High Need for blood Low Moderate to high Immediate Blood preparation Type and cross-match Type specific Type O PRBCs Management of non-hemorrhagic shock Operative intervention Possible Likely Highly likely

26. Transient responders or Non-responders to initial resuscitation Hemorrhagic shock ( Class III/IV) Non-hemorrhagic shock Tension pneumothorax Cardiac tamponade (Beck’s triad) Distended neck veins (Raised JVP) Muffled heart sounds Low BP No rmal breath sounds FAST Blunt cardiac injury Arrhythmias, ischemic ECG changes Others Neurogenic shock ( Hypotension, bradycardia , warm extremities) o r S eptic shock 6/2/2020 28

27. 29 Cardiac tamponade (Beck’s triad) Penetrating inury Volume replacement Pericardiocentesis Thoracotomy Blunt Cardiac injury Invasive monitoring Inotropic support Consider operative intervention Tension pneumothorax NON-HEMORRHAGIC SHOCK (besides neurogenic and septic shock)

28. HEMORRHAGIC SHOCK Massive haemothorax Intra-abdominal hemorrhage Distended abdomen DPL / FAST + ve Rectal, vaginal examination Volume replacement LAPAROTOMY Obvious external bleeding (musculoskeletal trauma) Identify source of external bleeding Direct pressure Splints Pelvic stabilization Closure of actively bleeding wounds Occult hemorrhage 6/2/2020 30 Source of occult hemorrhage: “Blood on the floor × 4 more” Chest Retroperitoneum Pelvis Long bones

29. Pelvic fracture stabilization Significant association with injuries to visceral or vascular structures Delay in stabilization of pelvis allows continued hemorrhage Repeated pelvic manipulation can aggravate hemorrhage Severe pelvic injuries warrant early transfer to trauma center 31 Pelvic binder Open book Vertical shear 6 -7 0 % Pelvic stabilization using bedsheet Lateral compression

30. Indications for Emergency Laparotomy Blunt trauma Hypotension with positive FAST/ DPL or clinical evidence of intra-peritoneal bleeding Free air, retroperitoneal air, rupture of hemi-diaphragm after blunt trauma Penetrating trauma Hypotension with penetrating abdominal wound Gunshot wounds traversing peritoneal cavity or retro-peritoneum (visceral/vascular) Bleeding from stomach, rectum, genitourinary tract Evisceration Peritonitis (even if no shock) 6/2/2020 34

31. D: Neurological status Avoid hypotension (SBP < 90) and hypoxia (PaO 2 < 60) Brief neurological examination: GCS: Best Motor Response Pupils: Ipsi -lateral pupillary dilatation with contra-lateral hemiparesis suggestive of uncal herniation Lateralizing signs 6/2/2020 35 GCS Classification 13-15 Mild traumatic brain injury (MTBI) 9-12 Moderate brain injury 3-8 Severe brain injury

32. E: Exposure and Environment Completely undress patient Warm environment Prevent hypothermia 6/2/2020 39 Core temperature < 35°C on admission: Independent predictor of mortality after major trauma (SHOCK 2005)

33. SECONDARY SURVEY STEP 1 . Obtain AMPLE history from patient, family. Or pre-hospital personnel. STEP 2 . Obtain history of injury-producing event and identify injury mechanisms. STEP 3 . Assess the head and maxillofacial area. STEP 4 . Assess the cervical spine and neck. STEP 5 . Assess the chest STEP 6 . Assess the abdomen

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35. SECONDARY SURVEY STEP 7 . Assess the perineum. STEP 8 . Perform a rectal assessment in selected patients to identify the presence of rectal blood. STEP 9 . Perform a vaginal assessment in selected patients. STEP 10 . Perform a musculoskeletal assessment. STEP 11 . Perform a neurological assessment.

36. TRANSFER TO DEFINITIVE CARE