The management of a polytraumatised

An overview of current practice in management of the multiply-injured individual

1. THE MANAGEMENT OF A
POLYTRAUMATISED PATIENT
PRESENTING AT THE EMERGENCY
DEPARTMENT
DR BASSEY A E
DEPARTMENT OF ORTHOPAEDICS

3. OUTLINE
•Introduction
•Definitions
•Epidemiology
•Statement of importance
•Aetiology
•Mechanisms of injury
•Management
•Primary survey and resuscitation
•Secondary survey
•Definitive treatment
•Complications
•Early
•Late
•Polytrauma in special populations
•Children
•Elderly
•Pregnant
•Current trends
•Conclusion

4. INTRODUCTION - Definitions
•Trauma – the exchange of energy between
the body and it’s environment exceeding it’s
resilience and leading to injury
•Significant trauma – is an injury which by
virtue of it’s location, extent, past or existing
complications, present or impending
haemodynamic instability will require hospital
admission and treatment

5. INTRODUCTION - Definitions
•Polytraumatised patient – is one who has
suffered 2 or more significant injuries to 2 or
more organ systems
•Emergency room – is a section of a healthcare
facility specializing in the provision of acute care
to patients presenting, without prior
appointment, with a broad spectrum of illnesses
and injuries which may be life-threatening,
arriving either by ambulance or their own means

6. INTRODUCTION – Epidemiology of
trauma
•Commonest cause of death in 1-44yrs
•3
rd
commonest cause of death overall
•Trauma mortality
–>90% of trauma mortality in low and middle
income countries
–50% in 15-44yrs
–M:F = 2:1
–RTA commonest cause

7. INTRODUCTION – Epidemiology of
trauma
•In Nigeria,
•Prevalence – 11.2/100,000
•Age – 27+/- 13yrs
•Sex – M:F = 2:1
•Trauma mortality
–Avg age – 29.5yrs
–M:F = 2.5:1
–RTA – 75%
–Polytrauma – 60.9%

8. INTRODUCTION - Statement of
importance
•Trauma is a public health problem of epidemic
proportion, and from data just supplied,
mortality is more associated with polytrauma
than isolated injury.
•Judicious application of in-depth knowledge
and well-honed skills is mandatory in order to
curb its devastating effects on individuals and
society.

9. AETIOLOGY
•RTA
•Fall from height
•Assault
•Terrorism
•Natural disasters
•Conflict

10. MECHANISMS OF INJURY
•Blunt
–RTA commonest cause
–Severity factors – mass & speed of vehicle, type of
vehicle, use of restraints, ejection from vehicle,
interaction with vehicle parts
•Penetrating
–Severity factors – mass & velocity of missile, viscera in
path of missile
•Blast
•Crush
•Thermal

14. MECHANISMS OF INJURY
•Trimodal pattern of death following trauma
•Immediate death
(50%) – 0-1 hr
(massive head inj.)
•Early death
(30%) – 1-3 hrs
(chest inj, exsanguinatn)
•Late death
( 20%) – 1-6 wks
(sepsis, org failure)

15. MANAGEMENT
•Multidisciplinary
•Orthopaedic surgeon
•General surgeon
•Anaesthetist
•Trauma nurse
•Radiographer
•Other subspecialties, as needed
•Time is of essence
•Golden hour concept

16. MANAGEMENT
•Aim of management
‘To return patient to pre-injury status or as
near as possible’
•Scale of priorities
•Save life
•Save limb
•Save looks

17. MANAGEMENT
•ATLS
–Developed in USA
–Adopted globally
•ATLS philosophy
Treat lethal injuries first

Reassess
Treat again

18. MANAGEMENT
•Primary survey and resuscitation
– Identify and treat what is killing the patient.
•Secondary survey
–Proceed to identify other injuries.
•Definitive treatment
–Develop a definitive management plan

19. MANAGEMENT - Primary survey and
resuscitation
•A – airway and cervical spine protection
•B – breathing
•C – circulation and control of external
haemorrhage
•D – disability status
•E – exposure and environmental control
Caveat – when patient has catastrophic limb
haemorrhage CABCDE is practised

20. MANAGEMENT
•Airway obstruction in the polytraumatised
patient results in death in a few minutes and
must be addressed immediately
•Assume c-spine injury in all polytraumatised
patients and immobilize
•In-line immobilization
•Device combination – rigid c-collar, sandbags, head
strap

23. MANAGEMENT
•Airway assessment
•High risk injury – TBI (commonest cause), maxillofacial
injury, neck injury, inhalational burn injury
•If conscious, elicit speech e.g. ask name. if unconscious,
search for following features,
•Restlessness, sweating, cyanosis, resp. distress, noisy
breathing, hoarseness of voice, stridor
•Use dorsum of hand to feel for breath

24. MANAGEMENT
•Interventions
–Carried out without extending neck
–The manoevres are carried out in a methodical
fashion with the simpler ones attempted first
–It serves as a guideline, however special situations
may require modification

25. Chin lift
Jaw thrust

Finger sweep/suction
oro/nasopharyngeal airway

Supraglottic airway eg LMA
tracheal intubation
surgical airway

26. CHIN LIFT

27. JAWTHRUST

34. Laryngeal mask airway

35. Endotracheal tube

36. Endotracheal tube in situ

37. MANAGEMENT
•Breathing
•Assessment
–Inspection – resp rate, shallow or gasping,
assymetry, contusion, penetrating wound, flail
segment, distended neck veins
–Palpation – tracheal deviation, tenderness,
crepitus, surgical emphysema
–Percussion – hyperresonance, dullness
–Auscultation – diminished BS, absent BS, noisiness

38. MANAGEMENT
•All polytraumatised patients should be given high
concentration oxygen at 15L/min via a
nonrebreathing face mask preferably
•Search for ‘lethal six’. Diagnosis is clinical.
–Airway obstruction – treated as previously stated
–Tension pneumothorax – cardinal signs are tracheal
deviation, hyperresonance, absent breath sounds.
Treatment: needle thoracostomy then CTTD
–Open pneumothorax
treatment: tape 3 sides of the wound leaving one side
for air venting

39. MANAGEMENT
•Massive haemothorax – tachpnoea, decreased
chest expansion, dullness, absent BS, shock
treatment – CTTD + thoracotomy
•Flail chest – treatment: intubation and PPV
•Cardiac tamponade – distended neck veins,
hypotension, muffled heart sounds
treatment: pericardiocentesis

42. MANAGEMENT
•Circulation and control of external
haemorrhage
•Assessment
–Patient may be agitated, confused, pale,
dehydrated, cold clammy extremities, increased
capillary refill time. Pulses may be rapid and
thready, hypotensive, oliguric/anuric
•To identify site of haemorrhage remember,
‘Bleeding onto the floor and four more’

43. MANAGEMENT
•Treatment
–Pass 2 wide-bore iv cannulae, at same time blood is
obtained for invx.
–Commence on iv crystalloids – N/S or R/L, 2L bolus
(consider intraosseous in children with difficult veins)
–Control external haemorrhage by
•Pressure and elevation
•Clamping and ligation
•Tourniquets
•Windlass technique
•Quikclot or HemCon have been found to be useful
–Pass urethral catheter and commence hourly urine
output monitoring after emptying bladder
–Transfuse transient and non-responders

46. Windlass technique

47. MANAGEMENT
•Disability
•Assessment
–AVPU – quick
–GCS – more detailed
•Exposure & environmental control
–All clothing removed
–Emergency room kept warm
–All fluids and gases warmed
–Warm blankets

48. MANAGEMENT
•Analgesia – opioids
•Antibiotics
•Anti-tetanus
•Adjuncts
•12-lead ECG
•Pulse oximetry
•Xrays (trauma series)
•Other investigations – as needed

49. MANAGEMENT
•Re-evaluation: following primary survey and
resuscitation, patient is re-evaluated and if
stable secondary survey commences

50. MANAGEMENT – secondary survey
•This is a detailed, systemic assessment of
patient to identify other injuries
•Usually done after primary survey but
sometimes may be done after surgery or in
the ICU
•ISS and MESS scores can be determined at this
time as well as more complex investigations
e.g. CT, MRI, angiography

51. MANAGEMENT
•Detailed history
–AMPLE
•Head-to-toe examination proceeding in a
systemic manner
–Head & face – open head injury, ocular inj, csf
otorrhoea or rhinorrhoea
–Neck – inspect for injury, swelling, palpate for
tenderness. Inspect c-spine starting from occiput.
Palpate for tenderness, haematoma, step

52. MANAGEMENT
•Chest – review primary survey and perform
full exam
•Abdomen and pelvis – inspect for distention,
penetrating wounds, palpate for tenderness, a
4-quadrant tap or DPL may be done at this
stage if haemoperitoneum is suspected. Pelvic
compression test. Inspect perineum for
lacerations, ecchymosis. Do DRE, and in the
female a vaginal exam in addition

53. MANAGEMENT
•Extremities – examine for swelling, deformity,
tenderness, crepitus. Note neurovascular status.
Obviously deformed limbs should be reduced and
immobilized using cast or traction for example
•Neurological assessment – full neurological exam
and sensory or motor deficit documented, spine
surgeons or neurosurgeons called in.
•Log-roll – requires at least 4people. Examine back
for swellings, wounds eg gunshot. Examine spine
from occiput to sacrum.

54. Missed injury!!??

55. MANAGEMENT
•Transfer for definitive care is done following
secondary survey.
•Care is tailored to patient’s injuries

56. COMPLICATIONS
•Early
•Shock
•AKI
•Sepsis
•Tetanus
•Fat embolism
•DIC
•Late
•ARDS
•MODS
•Demise

57. POLYTRAUMA IN SPECIAL
POPULATIONS
•Children
•Falls & RTA cause 90% of paediatric polytrauma
•RTA commonest cause of death
•Consider child abuse as a cause
•Dosing of fluids and medication according to weight is
essential
•Higher surface area-to-volume ratio means child is at greater
risk of hypothermia, increased emphasis on warmth
•Children have increased blood loss associated with long
bone and pelvic fractures compared with adults; therefore,
early splinting and stabilization are even more important
•Children initially respond to hypovolemia with tachycardia
and may not drop their blood pressure until they have lost
45% of their circulating volume
•Consider early transfer to a pediatric trauma center.

58. POLYTRAUMA IN SPECIAL
POPULATIONS
•Elderly
•Elderly are less likely to be involved in trauma but are more
likely to die from it
•Falls 2
nd
commonest cause in 65-74yrs group; commonest in
>75yrs group
•Consider elder abuse as a cause
•Elderly may not be able to mount a tachycardic response to
shock because of medications or reduced sensitivity to
sympathetic outflow.
•A seemingly normal blood pressure might actually be
dangerously low in a patient with baseline hypertension
•Fluid overload may be as dangerous as hypovolemia.
Consider invasive monitoring

59. POLYTRAUMA IN SPECIAL
POPULATIONS
•Pregnant
•Trauma is commonest cause of non-obstetric M & M
•Patients at high risk of pulmonary aspiration, consider
early NG tube placement & rapid sequence intubation
if ET airway required
•After 12 wks, foetus is vulnerable to abdominal trauma
incurred by mother, therefore fetal age assessment
and viability becomes part of primary survey
•Early consultation with an obstetrician-gynecologist is
recommended

60. CURRENT TRENDS
•Permissive hypotension
•Rise of regional trauma centres

61. CONCLUSION
•Trauma remains the ‘neglected step-child of
modernisation’.
•The burden of trauma mortality, mainly
resulting from polytrauma, rests upon us in
developing nations.
•Training and retraining of doctors and
healthcare professionals as well as enactment
of adequate, specific and appropriate policy
with widespread implementation of same will
go a long way in lightening this burden.

62. THANK YOU

63. REFERENCES
•Apley System of orthopaedics and fractures,
9
th
Ed, pp627-687
•Bailey & Love short practice of surgery, 25
th
Ed,
pp285-298
•http://emedicine.medscape.com/article/1270
888-overview#a6
•http://www.scopemed.org/?mno=9087
• Lateef O.A. Thanni (2011). Epidemiology of
Injuries in Nigeria—A Systematic review of
Mortality and Etiology. Prehospital and
Disaster Medicine, 26, pp 293-298

64. REFERENCES
•https://en.wikipedia.org/wiki/Emergency_depart
ment
•http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1
831976/
•https://en.wikipedia.org/wiki/Injury_Severity_Sc
ore
•https://en.wikipedia.org/wiki/Polytrauma
•http://www.ncbi.nlm.nih.gov/pubmed/2239047
•http://www.slideshare.net/prithwiraj2012/polytr
auma-2