POLYTRAUMA

PRIMARY AND
SECONDARY SURVEY
Concept And Overview Of Trauma
Death - Trimodal Distribution

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TRAUMA DEATH
The First Peak of Death is within seconds to minutes
of injury.
Causes:
1. Laceration of the Brain.
2. Brain Stem injury.
3. High Spinal Cord Injury.
4. Heart, Aorta and Large vessels lacerations.
* Only prevention can reduce this peak trauma related death
* Usually non-salvageable

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Undergraduates CME 5
 TRAUMA DEATH
The Second Death Peak occurs within minutes to
several hours after injury.
Main focus of Trauma Life Support is in this peak.
This period is referred to as the Golden Hour.
Conceptionally, Golden Hour - First Hour
Characterized by;
1. Rapid Transportation
2. Rapid assessment and stabilization
3. Rapid definitive care
Undergraduates CME 6
 TRAUMA DEATH
Second Peak of Trauma Deaths are
preventable and managable.
Conditions include:
A. Subdural/Extradural Haematoma.
B. Haemo-pneumothorax.
C. Ruptured Spleen/Liver lacerations.
D. Pelvic Fractures.
E. Multiple injuries associated with significant
Undergraduates CME 7
blood loss.
 TRAUMA DEATH

The Third Peak of Death occurs several

days or weeks after initial injury.
Causes:
1. Sepsis.
2. Organ Failure.

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WHAT IS POLYTRAUMA ?

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 POLYTRAUMA

Definition :
A Clinical syndrome where a patient
sustained serious injuries involving
two or more major organ and
physiological systems.

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Initial Assessment
Injury
Transfer
Primary Survey
Optimize patient
Adjuncts
status
Resuscitation
Reevaluation
Reevaluation
Secondary Survey
Adjuncts
PRIMARY SURVEY :-

Definition :-

The Preliminary Assessment of a patient which

is conducted in a systematic manner with the
objective of identifying life threatening
conditions and managing them as soon as they
are found.

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 THE FIRST PERSON TO
ASSESS THE PATIENT CAN
AFFECT THE FINAL
OUTCOME

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 Primary survey and
resuscitation of vital
functions are done
simultaneously.

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 PRIMARY SURVEY

Should not take more than 2 minutes

should not be interrupted unless there
is airway obstruction or cardiac arrest

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PRIMARY SURVEY

IMMEDIATE ASSESSMENT
A. AIRWAY & CERVICAL SPINE CONTROL
B. BREATHING & VENTILATION
C. CIRCULATORY FUNCTION & HEMORRHAGE
CONTROL
D. DISABILITY & NEUROLOGICAL STATUS
E. EXPOSURE & UNDRESS COMPLETELY

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PRIMARY SURVEY - AIRWAY
1. GENERAL INSPECTION

ANY LIFE THREATENING CONDITION DETECTED MUST BE

CORRECTED SIMULTANEOUSLY *

-ATOMFC-
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 Airway Obstruction
Causes:
Presence of secretions and foreign matter
in the mouth.
Tongue falling back in the unconscious
patient.
Deformity and injury to the airway
including maxillofacial injuries.
Swelling and inflammation of the airway as
in burns injury or ingestion of toxic
substances.
laryngospasm 18
AIRWAY MANAGEMENT
PRIMARY SURVEY
1. Blood/Secretions - Suction/removal of
debris.
2. Floppy Tongue - Oropharyngeal airway
Airway and bag
3. Maxillo-facial injury - Attempt reduction,
intubation or
cricothyrodotomy.
4. Mechanical blockade - Finger sweep and
removal of
object.
5. Partially Airway Obst. - jaw thrust / chin-
Protection of the C-spine
Assume that the C-spine is damaged in any
injury above the clavicle.
Examination of the neck is to be done
together with manual immobilization.
Note any injury to the neck
e.g tracheal deviation
surgical emphysema
the neck collar must be rigid and of the
correct size.

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Undergraduates CME December 12, 2011 21
PROTECTION OF THE C-SPINE

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PROTECTION OF THE C-SPINE

Any injury above the

clavicle
Unconscious
polytrauma
Neck pain

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BREATHING PRIMARY SURVEY (CONT)

CHEST EXAMINATION
General Inspection
Look - obvious injuries/deformities.
- chest movement.
During Inspection
Open chest wound - air tight seal.
Implanted object - anchor object & seal
wound
* DO NOT REMOVE OBJECT*
Examination of Chest
Apex beat, chest expansion & percussion
note.
Spring Test
Positive- conscious - tenderness at
fracture site.
- unconscious - laxity of rib-cage
Auscultation
- Apex site
- Quality of heart sound.
- Air entry and Abnormal sounds.
PRIMARY SURVEY (CONTD)
Life threatening conditions must
be diagnosed and treated
immediately.
1. Airway Obstruction.
2. Tension Pneumothorax.
3. Open Pneumothorax.
4. Massive Haemothorax.
5. Flail Chest.
6. Cardiac Tamponade.
 TENSION
PNEUMOTHORAX
* One-way valve
mechanism
* Air trapped in
pleural space
* Increase press. in
pleural space
* Lung collapse
with mediastinal
shift

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Undergraduates CME 28
TENSION PNEUMOTHORAX
SIGNS
1. Tracheal Deviation
2. Respiratory Distress
Absence of breath sounds -
Unilateral
Distended Neck Veins
Cyanosis Late
DIAGNOSIS - Clinically, NOT Radiological
MANAGEMENT
Needle Thoracocentesis
Chest Tube Insertion
MASSIVE HAEMOTHORAX
More than 1500 ml of blood lost into the
chest cavity or drain 1.5 L stat or 600 ml/6H
(600 ml/H for 1 hour or 100 ml/H for 6H or
200 ml/H for 3H) by chest tube.
Usually due to penetrating injuries that
disrupt the systemic or pulmonary
vasculature.
Signs:
1. Dyspnoea
2. Hypoxia
3. Flat / distended neck veins
MASSIVE HAEMOTHORAX

MANAGEMENT
1.Rapid Volume Restoration
2.Chest Tube Insertion
3.Thoracotomy - consider if
blood lost is more than
600ml/6H
OPEN
PNEUMOTHORAX
Large defects / open
wounds (diameter of
wound > than
trachea) causing
sucking chest
wounds.
Equilibration
between
intrathoracic and
atmospheric pressure
resulting in
impairment of
effective ventilation.
OPEN PNEUMOTHORAX

MANAGEMENT:
1.Cover defect with sterile
occlusive dressing.
2.Chest tube insertion.
3.Definitive surgical closure.
OPEN PNEUMOTHORAX ( SUCKING CHEST WOUND )
Occlusive Dressing

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 Flail Chest
When a segment of
chest wall does not
have bony continuity
with the rest of the
thoracic cage

Usually defined as at
least two fractures per
rib ( producing a free
segment) in at least
two ribs

December 12, 2011 38

 FLAIL CHEST

MANAGEMENT
Adequate ventilation &
Oxygen
Volume restoration
Analgesia
CARDIAC TAMPONADE
COMMON CAUSES
- Penetrating injuries
- Blunt injury
CHARACTERISTIC
BECKS TRIAD
- Elevated JVP
- Muffled Heart Sounds
- Distended Neck Veins
Narrowed Pulse Pressure
 CARDIAC TAMPONADE
In trauma, as little of 150 ml 200 ml of
blood in pericardium can caused sign of
cardiac tamponade

MANAGEMENT
- PERICARDIOCENTESIS
- OPEN THORACOTOMY
CARDIAC TAMPONADE
PRIMARY SURVEY (CONTD)

CIRCULATION & HEMORRHAGE

CONTROL
GENERAL ASSESSMENT
skin color & temperature
pulse rate, blood pressure
capillary refill
identify source of bleeding
Inspect, palpate and auscultate
abdomen
Pelvic spring
* DONT WAIT UNTIL THE BLOOD PRESSURE FALLS TO
SUSPECT SHOCK AND BEGIN TREATMENT *
MANAGEMENT OF THE CIRCULATING
SYSTEM

Control bleeding site by pressure

bandage
Insert 2 large caliber IV cannula
Rapid infusion of volume replacement
Send blood for blood GXM
Insert urinary catheter & naso-gastric
tube (unless contraindicated)
DISABILITY & NEUROLOGICAL
STATUS
AVPU/GCS

Pupillary signs

Spine tenderness and per rectal

examination

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 EXPOSURE/ENVIRONMENT
Undress patient completely
- Thorough examination so that not miss any injury
- Pelvis
- Groin
- Genitalia
- Back

Keep patient warm

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 Reassessment
Reevaluate ABCDE

Reevaluate vital signs

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 Primary Survey
Primary survey adjuncts
Blood Ix , glucose
ECG , ABG
Plain xray
Cervical spine
Chest
Pelvis

FAST
Focused assessment with sonography in trauma
For detection of fluidUndergraduates
in peritoneal CME and pericardial 48
space.
SECONDARY SURVEY
HISTORY
- Past Med. History / Allergies
- Current medications
- Mechanism of Injury
- Patients Condition at the Field
- Other Relevant Details

PHYSICAL EXAMINATION
- Head & Neck
- Chest
- Abdomen
- Musculoskeletal
- Neurological
Secondary survey adjunct

CT scan
Ultrasound
Bronchoscopy
RE-EVALUATION

Because of the dynamic state of the

physiological systems, the condition
may change within a short period of
time. Hence, after each primary &
secondary survey a complete RE-
EVALUATION of all the vital systems
must be carried out.
Always Work in Team
THANK YOU