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Approach for poly-

trauma patient

Dr. Hany Victor


Lecturer of Anesthesia and ICU
ETC Instructor
Objectives
Case presentation on poly-trauma

patient.
Discussion on the case

Approach to poly-trauma patient

Recommendation

MCQ
Case
Male patient 28 years presented to the ER

following a motor car accident 30 min ago


complaining of chest pain, cut wound in the
forehead with minimal bleeding and pain in
the right forearm.
By history the patient had a blunt trauma to

the head and chest in the dashboard. Other


previous medical history is irrelevant.
On examination
Airway: Clear
Cervical Spine immobilization after neck
examination with no major abnormality
Breathing:
RR: 20/min

Equal air entry bilateral with no adventitious sounds.

Tenderness over the sternum.

SpO2: 95% on room air.


Circulation:

There is no major site of bleeding, vital signs include:


HR: 100/min felt central and peripheral, equal on

both sides.
Blood pressure: 100/60 mmHg.

Capillary refill time: 1.5 sec.

Temp: 37.1C

Neck veins not congested

There is wound in the forehead 5X3 cm.


Disability
GCS 15/15
No loss of cons, no nausea or vomiting, no bleeding
per orifices, no transient amnesia and no fits.
Pupils are equal bilateral and reactive to light.

Blood sugar 140 mg/dl.

Exposure
No major bleeding

No major deformity
Discussion on part
one of the lecture
Types of assessment
1. Primary Survey and resuscitation

Identification of Life threatening


conditions
AcBCDE Approach

2. Secondary Survey

Detailed head to toe examination


Medical history
All lab and radiology investigation
ordered 8
PURPOSE OF THE INITIAL
ASSESSMENT

Identification of LIFE-
THREATENING emergencies
Assess Change - Reassess

Initiation of LIFE-SAVING
measures (CPR)
Illinois EMSC 9
5 second Round
Pt is conscious or not
Airway
Ventilation
Signs of massive external
hemorrhage
There is any deformity
Skin color and temp with feeling
Illinois EMSC 10
Primary Survey
Airway/
Cervical Spine Control
Breathing
Circulation
Disability (neurological)
Expose
Illinois EMSC 11
Assessing Airway

Is the airway:

Clear and safe?

At risk?

Obstructed?
AIRWAY INTERVENTIONS
Jaw thrust Vs Head tilt.
Deliver Oxygen (mask
with reservoir).
Use Rigid suction.
Secure airway.

Illinois EMSC 13
5 Chest clues in the
neck
Wounds
Distended neck
veins
Tracheal
position
Surgical
emphysema
Laryngeal
crepitus
CERVICAL SPINE STABILIZATION

Place hands on either side


of the head cervical collar.flv

Maintain neck midline


manual in line
stabilization
Illinois EMSC 15
Breathing and
ventilation
Aims
Support if
inadequate
Eliminate any
immediately life
threatening
thoracic
condition ..
Breathing and
ventilation
Inspection
Respiratory rate
Effort of breathing
Symmetry
Auscultation
Wounds & marks
All lung zones

Palpation
Tender points, equal
expansion

Percussion
No abnormal note
BREATHING INTERVENTIONS

If breathing is absent, start


ventilation using:
Simple Adjuvants (Airways)
Bag valve mask with reservoir
LMA
ETT

Illinois EMSC 18
Fatal Chest conditions?
Tension pneumothorax

Open chest trauma

Cardiac tamponade

Flail chest

Massive hemothorax

Illinois EMSC 19
CIRCULATORY ASSESSMENT
Carotid pulse (absent or
present)
Capillary refill
Skin color
Skin temperature
Sites of bleeding

Illinois EMSC 20
CIRCULATORY INTERVENTIONS
If central pulse is absent, begin
CPR
Apply direct pressure to open
wounds
IV access (2 wide bore
cannulae14/16G).
Fluids (colloids Vs crystalloids) 20ml/Kg
Peripheral Vs central line?
21
Dysfunction of the
CNS
Aims
Rapid neurological
assessment
Alert; Voice; Pain;
Unresponsive
Pupils
Mini-neurological
assessment
GCS score / AVPU
Pupils
Lateralising signs
Blood sugar
23
Exposure and
environment
Aims

Remove clothing to allow examination of

entire patient
Care when removing tight trousers

Prevent hypothermia

Patient dignity

Remove spine board


Dont Forget The Back
Pause & check
Are all immediately
life-threatening
injuries identified?
Is all monitoring in
place?
Investigations
ordered?
Analgesia?
Relatives informed?
Non-essential team
members disbanded?
The well practiced
trauma team should
aim to complete the
primary survey in
less than 10
minutes

Illinois EMSC 27
Radiology
Once the patient is stabilized the patient is
sent to radiology for the survery:
Cervical spine X-ray (AP and lateral view)
Chest X- ray (Rib cage)
Pelvis X-ray
Abdomen and Pelvis U/S
CT brain is ordered if there is suspicion of
head trauma
X-ray of extremities if fracture is suspected.
Chest X-Ray
Part 2 case
Patient returned form the radiology
department complaining of severe chest pain
and could not lay down on his back for
suturing of the cut wound in the forehead
Patient received the following medication:
1500 cc of normal saline

cefoperazone 1.5 gm IV

Analgesia as Perfalgan 1gm IV followed by


Pethedine 50 mg IM
Labs were send for urgent Hb
Patients Vital signs were:
HR: 120/min
Blood pressure 85-90/50-60 mmHg.
CRT 2 sec
SpO2:92 % On Room air.

Patient still complains of severe chest pain


and received another 50 mg pethedine over
100 cc Normal Saline over 30 min
Differenti
al Diagnosis
s t e p
n e x t
t h e
a t i s
W h
What Labs to order?

What other radiological

investigations to ask for?

What other medications to give?


Chest X-Ray

Mediastinal widening

Double aortic knob sign


Diffuse enlargement of the aorta
Tracheal displacement to the right
Pleural effusion
CT chest
Aortograghy
Aortograghy
Final Diagnosis
Traumatic aortic tear
THORACIC
TRAUMA
Traumatic Aortic Rupture
These are found in victims of high-speed motor

vehicle crashes and falls from great heights, and


85% of these injuries are due to blunt trauma.

The majority (80-90%) of the patients die at the

scene of the accident from massive blood loss. Of


the patients reaching hospital alive, only 20% will
survive without operation.

The mortality remains high even after surgery.


In cases of aortic rupture, the clinical

presentation depends upon the site of injury.


Patients with injury to the intrapericardial
portion of the ascending aorta will usually
develop a cardiac tamponade.
Extrapericardial ascending aortic injury

produces a mediastinal haematoma and a


haemothorax, usually on the right side
Rapid deceleration is believed to be

responsible for damage to the aorta that


most commonly occurs in the region of
ligamentum arteriosum, just distal to the
origin of left subclavian artery.
Patients may show transient hypotension, which

responds well to fluid therapy and further

clinical signs may be absent.

This may delay the diagnosis with catastrophic

results should the aorta rupture completely.

Thus a high index of suspicion should be kept in

mind.
Aortic disruption should always be suspected

in patients with profound shock and who have

no other external signs of blood loss and in

whom mechanical causes of shock (tension

pneumothorax and pericardial tamponade)

have been excluded.


Symptoms (if the patient is conscious) may
include:
Severe retrosternal pain

Pain between the scapulae

Hoarseness of voice (pressure from

haematoma on the recurrent laryngeal


nerve)
Dysphagia

Paraplegia or paraparesis

Aortic dissection Vs ACS.


The definitive investigation of choice is

angiography or a CT angiogram of the aortic

arch, the choice depending on local policy.

Survival in patients who have their injury

repaired surgically and who have remained

haemodynamically stable during the repair is

90%.
Minimally invasive repair using aortic stenting
techniques are also being used
MANAGEMENT OPEN
PNEUMOTHORAX
Ensure adequate
airway
100% oxygen
Seal open wound
Load & Go
IV access en route Courtesy of David
Notify Medical Effron, M.D.

Direction
SEALING THE OPEN WOUND
Asherman chest seal is very effective
SEALING THE OPEN WOUND
You can use impervious material taped on
three sides
TENSION
PNEUMOTHORAX
MANAGEMENT
TENSION PNEUMOTHORAX
Ensure adequate airway
100% oxygen
Needle decompression if indicated
Load & Go
IV access en route
Notify Medical Direction
MCQ
1. Which of the following is true in regards to a
traumatic aortic rupture?

A. There is a 50% survival rate

B. Immediate defibrillation is indicated

C. Usually due to deceleration injury

D. They are easily diagnosed in the pre-


hospital setting
3. What is the MOST likely abnormality that would
be seen on chest x-ray in a patient with
traumatic rupture of the aorta after blunt injury?

(A) Obscuration of the aortic knob

(B) Deviation of esophagus to the left

(C) Fracture of the first or second rib

(D) Apical cap

(E) Superior mediastinal widening


3. Male patient with intracerebral
hemorrhage and intra-abdominal bleeding,
the optimum blood pressure for this
patient should be maintained around:

A. 90 mmHg.

B. 100 mmHg.

C. 110 mmHg.

D. 70 mmHg.
4. The initial management of a poly-trauma patient
should include the following order:
A. Conscious level, secure airway, assess circulation ,
control cervical spine, assist ventilation and
exposure.
B. Secure airway, control cervical spine, assess
circulation, follow up conscious level and assist
ventilation and exposure.
C. Secure airway, control cervical spine, assist
ventilation, assess circulation, follow up conscious
level and exposure.
D. control cervical spine , secure airway, assist
ventilation, assess circulation, follow up conscious
level and exposure.
5-Which of the following is the BEST screening
test for detecting traumatic aortic injury in a
stable patient?
(A) Chest radiograph.

(B) Computed tomography aortography.

(C) Trans-thoracic echocardiography.


(D) Test for unequal blood pressures in the
upper extremities..
Recommendations
All Trauma patients should be assessed using the

universal AcBCDE approach.


Management of Poly-trauma should include primary and

secondary survey.
Team work is standard in management of trauma

patients.
Routine investigation should be implemented as a

protocol for our policy in Demerdash and ASUSH.


High index of suspicion should be kept for aortic trauma

in any posttraumatic chest pain.


QUESTIONS?
THANK YOU