Approach to POLY TRAUMA

Dr Indira Jayakumar
Senior Consultant
ER & PICU
Apollo Childrens Hospital
Golden Hour
Transport
Effect of trauma center designation on outcome in patients with severe traumatic brain injury.
Arch Surg 2008 Dec;143(12):1213-7
PTS < 8 – concerning !!
Protect Yourself First
Chaos to........ Calm, Confident ,Control
Team leader assigns roles
Keep Track of Events
 Purpose of “ Primary Survey ”

• Identification of “LIFE-THREATENING ” emergencies

• Initiation of “LIFE-SAVING ” measures

Treat what kills first !!

13
Primary Survey

Airway
Breathing
Circulation
Disability
Exposure
 The well practiced
trauma team should
aim to complete the
primary survey in less
than 10 minutes

Illinois EMSC 15
 Assess Airway
Is the airway:

• Clear and safe?

• At risk?

• Obstructed?
 Cervical Spine Stabilization
• Place hands on either side of the head

• Maintain neck midline “manual in line stabilization”

18
 Airway and Cervical spine
• Always assume that patient has cervical spine injury
• If patient can talk then he is able to maintain own airway
• If airway compromised , initially attempt a chin lift and do
suction with wide bore yankauer sucker .

• Give 100% Oxygen

• Intubate
• No NG tube – only OG
 Breathing and ventilation

Aims
• Support if inadequate

• Eliminate any immediately life

threatening thoracic condition
…..

• Percuss , Auscultate
Tension Pneumothorax
Traumatic Hemothorax
 Circulation and Haemorrhage Control
• Assess pulse, capillarycontrol
return , perfusion

• Place two large calibre peripheral intravenous cannulas

• Attach patient to ECG / BP monitor

• Identify exsanguinating haemorrhage

• External bleed – direct pressure

• Give intravenous fluids (crystalloid x2 , O neg blood )

 Causes of shock in trauma

• Haemorhage -scalp, chest , abdomen , pelvis , femur

• Obstructive- tension pneumothorax ,

pericardial effusion

• Cardiogenic - myocardial stunning

• Neurogenic
•
Scalp Hematoma in infants
 What is the FAST exam?

• Focused Assessment by Sonography in Trauma

• Focused exam using ultrasound to diagnose hemorrhage in a
trauma setting
• Ideally takes < 3 min
• 4 primary views
– RUQ
– LUQ
– Subxiphoid
– Suprapubic
RUQ LUQ
Subxiphoid Suprapubic
 Limitations of FAST

• Retroperitoneal bleeding

• Inadequate volume of fluid

• Not enough time elapsed since trauma

• Image quality dependent - USG machine / probe,

body habitus ,
physical injuries
• Scan and interpretation are operator dependent
 Assessment for Pelvic Trauma

• Check for bruising, deformity , blood in meatus

• Fracture femur / abdominal trauma /urethral rupture ass
• Blood may enter retroperitoneal space- normal FAST
• No Urinary catheter in suspected pelvic trauma
Pelvic Stability Assessment - do ONLY ONCE
1) Medial pressure 2) Posterior iliac pressure

3) Posterior pubis pressure

 Pelvic Binder- when to apply ?
(suspected abdominal , femur , pelvic injury
hemodynamically unstable )

Wrap and twist the running

Locate the great trochanter ends around the pelvis
Pelvic Binder – greater trochanter
 “ Damage Control Resuscitation ”
• Permissive Hypotension

• Hemostatic Resuscitation + aggressive warming

( PRBC , FFP, platelets 1:1:1 )

• Damage control surgery

“ Avoid Bloody Vicious Cycle ”

Damage control resuscitation for patients with major trauma BMJ 2008
First Arrest Bleed !!!
 Trauma
( Hemodynamics )

Unstable Stable

Hemostatic
resuscitation Damage control
surgery Conservative
Permissive
Hypotensiom
Blood Pressure in Traumatic Brain /Spinal cord Injury

Cerebral Perfusion pressure =

Mean Arterial pressure – Intracranial pressure

N CPP = MAP –  ICP

 Neurogenic shock
• Spinal cord injuries above T1 level ( anal tone lost )
• Unopposed parasympathetic activity since sympathetic
supply cut off - Bradycardia & Vasodilatation
• Rx – pressors ( noradrenaline ) , atropine
• NO STEROIDS

CNS / AANS Guidelines

 Head Injury
• Mild - GCS 12- 15
• Moderate - ,, 9-11
• Severe - ,, 3- 8

Rx - intubate for severe / sedate / PaCo2 35

- head end elevation
- 3% saline ( mannitol only sos )
- prophylactic anticonvulsant
- euthermia , euglycemia
 Unequal Pupil in Trauma

• Ipsilateral Uncal Herniation (if GCS < 8)

• Local Injury ( rare )
 Compartment Syndrome
• Do not wait for Pulse to disappear

• Cold , painful , tender, tense – do fasciotomy

Log Roll
 Primary Survey - Investigations

• Xray – chest , pelvis , lateral neck

• FAST

• CT brain and spine

 Pause & check

• Are all immediately life-threatening injuries identified?

• Is all monitoring in place?
• Investigations ordered? ( CT when hemodynamics stable)
• Analgesia?
• Relatives informed ?
• MLC done ?
Bicycle handle Injury –Hepatic laceration
resuscitated In ER and soon taken to OT
 Hematoma – needs drainage

• Extradural Hematoma • Subdural Hematoma

Traumatic Hydrocephalus
 Traumatic Brain Injury –
Decompressive Craniectomy
Mock Drills – Trauma
Thank You
 Scenario -1
A 12 year old boy who was trying to experiment his dad’s
new motorcycle, collides on to a retaining wall. At the
injury scene he is combative and his GCS score is 11.

His BP-80/50 mm Hg, HR-110/min RR-48/min.

A semirigid cervical collar is applied, and he is

immobilized on a long backboard. He is receiving oxygen
via a high flow oxygen mask. Shortly expected to arrive in
ACH ER.
Scenario-1
Scenario -1
 Scenario-2
At a construction site involving five workers, one
adolescent boy (16 yrs) sustained injury after a fall from
a height of 20 ft.
He is immobilized with semirigid cervical collar and
secured to a long backboard. High-flow oxygen is being
administered via a face mask.
Shortly after his arrival in the ED he complaints of pain in
the right side of chest. BP- 82/60 mm Hg, HR-140/min,
RR-46/min.
Scenario-2
 Scenario-3
An explosion and fire due to faulty gas line occurred
in an enclosed room, involving 5 members of same
family. All are immobilized on a long spineboard, and
the child(6 yr) alone shifted to ACH ER. She appears
frightened/crying. She reports pain from burns
(erythema/blisters), over the back, buttocks and both
legs posteriorly. BP-70/50 mm Hg, HR-150/min,
RR-25/min. After few minutes of arrival in to ER (1
Hr from the time of event), she started coughing and
expectorating carbonaceous material.
Scenario-3
 Scenario-4

A 12-yr old boy ejected from a vehicle during an automobile

collision. He was initially unconscious for at least 5mins.
He now opens his eyes to speech, moves only to painful
stimuli by withdrawing his extremities and utters
inappropriate words.

BP- 180/80 mm Hg, HR- 60/min , RR – 30/mt,

sats – 94 % RA
Scenario-4
 Scenario-5

At a construction site, a wall collapses on a 15-yr old boy.

He is screaming and reports pain in his legs

BP-90/72mm Hg, HR-110/min, RR-22/min, GCS -15/15

Scenario-5
 TRAUMA MCQs ???
1. Gurgling, stridor, snoring are signs are complete airway
obstruction.
2. Patient who doesn’t have gag reflex need intubation to protect
airway.
3. Coagulapathy, acidosis and hypotension form the lethal triad.
4. Cerebral perfusion pressure = SBP – ICP.
5. In calculating percentage of burns, infants occupy larger
proportion for legs than head, when compared to adult.
6. Best way to insert chest drain in open pneumothorax is
through open wound to decrease further trauma to lung.
7. CSF rhinorrhea implies middle cranial fossa fracture.
8. Cushings reflex means hypertension with bradycardia.
9. “ A “ in AMPLE history stands for-------------.
10. Pulse probe is useful tool to monitor Co2 retenion too