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Early management of polytrauma

Purnendu Saxena
MS(Orth), DNB (Orth), DOrth (UK), MCh Orth (UK), FRCS (Trauma and Orth)(UK)

Why

Trauma care is need of our society Mortality is high Most of the victims are young and the resultant loss to the families are catastrophic Many of these deaths are preventable

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Early care
Requires a wider understanding and not a specialists approach Requires that life threatening priorities are dealt urgently A complete clinical assessment should not be neglected while priorities are being managed Surgical procedures are tailored as per patients general condition
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Steps in trauma management

Primary Survey
Identify life threatening conditions following ABCD Manage life threatening conditions Start resuscitation

Secondary survey
Assess everything Head to toe

Early definitive management


Damage control surgeries Continued care in ICU

Final definitive management

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PRIMARY SURVEY

Priority is ABCDE A- Airway and neck B- Breathing C- Circulation D- Disability E- Environment control This is not a formula to remember for exam!

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Why ABCD

Your brain can work only if it can get oxygenated blood through circulation The circulating blood is useful only if it can get oxygenated within breathing lungs A functional lung can be useful only if it get air through a patent airway

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Why ABCD
fix the Airway first fix the Breathing lungs next fix the Circulation and then fix the Disability (brain & bones)

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What is Airway

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What to see

Is there an obstruction Is there any impending obstruction

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What to do

Support it (remember cervical spine) Clean it Assist Intubate Surgical airway

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Monitoring

Put pulse oximeter

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Breathing

Conduction of air is the function of Airway Breathing is a process in which gaseous exchange takes place Breathing is the function of lungs and ribcage

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What to see and why

Trauma Clinicians Often Miss Fractures Tension pneumothorax Cardiac temponade Open wound Massive pneumothorax Flail chest
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What to do

Tension pneumothorax
Urgent decompression

Cardiac temponade
Urgent decompression

Open wound
Seal as a valve

Massive pneumothorax
Drain it and put a chest tube

Flail chest
Ventilatory support

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Monitoring

Put ECG leads

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Circulation

Circulatory failure leads to reduced tissue perfusion that is Shock Hemorrhagic shock -most likely Nonhemorrhagic
Neurogenic shock Septic shock Mechanical shock pump failure

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What to see

Pulse Skin colour and temperature Blood pressure Urine output Consciousness

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What to do

Stop obvious bleeding Restore volume rapidly (Fluid challenge) See the response

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Monitoring & interventions


Two veinflons Take blood sample Start iv fluids Blood pressure monitoring ECG monitoring

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Disability

Head injury Fractures

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What to see

AVPU Alert Respond to vocal stimulus Respond to painful stimulus Unresponsive

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What to do

Early management is restoration of ABC Communication

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Environment

Completely undress Hypothermia prevention

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Completion of primary survey

At the end of primary survey Get lateral view of C/S Chest Xray Pelvic Xray Cathaterise / intubate / ryles tube if required Start life saving maneuvers like intubation, decompressing tension pneumothorax, and giving IV fluid Consider need for transfer
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Secondary survey

Life threatening priorities are identified and their management is started in primary survey Secondary survey focuses on
History Head to toe exam & more complete investigations Deciding priorities

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History (AMPLE)

Allergies Medications currently taken Past illness Last meal Event leading to injury

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Head to toe examination

Secondary survey Total patient evaluation


Head & skull, Maxillofacial Neck, Chest,Abdomen Perineum Musculoskeletal Complete neurological exam

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Complete investigations

At the end you should have All Xrays CT / US/ laboratory investigation Tubes and fingers in all orifices

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Fixing priorities

Communication with all subspecialties Priorities discussed

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Early definitive care

There is a controversy Is patient fit enough to undergo another trauma in the form of surgery ? (Dont touch!) Will patient improve / survive without having done a surgery ? (Do it now!)

Damage control surgeries are the middle path ( Do the minimum!) Continued care in ICU

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Definitive treatment

Do whatever you like

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Summary

Primary survey
Life threatening priorities managed (ABCD)

Secondary survey
Head to toe exam and all the injuries identified

Early definitive care


Damage control surgeries Management in ICU

Definitive management

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Thanks