Approach for polytrauma 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

PURPOSE OF THE INITIAL

ASSESSMENT
Identification of LIFE-

emergencies
Assess Change - Reassess
THREATENING

Initiation of LIFE-SAVING

measures (CPR)
Illinois EMSC

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

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Primary Survey
Airway/

Cervical Spine Control

Breathing
Circulation
Disability (neurological)
Expose
Illinois EMSC

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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

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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

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Breathing and
ventilation
Aims
Support if
inadequate
Eliminate any
immediately life
threatening
thoracic
condition ..

Breathing and
ventilation
Inspection
Respiratory rate
Effort of breathing
Symmetry
Wounds & marks
Palpation
Tender points, equal
expansion
Percussion
No abnormal note

Auscultation
All lung zones

BREATHING INTERVENTIONS
If breathing is absent, start

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

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Fatal Chest conditions?

Tension pneumothorax
Open chest trauma
Cardiac tamponade
Flail chest
Massive hemothorax
Illinois EMSC

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CIRCULATORY ASSESSMENT
Carotid pulse (absent or

present)
Capillary refill
Skin color
Skin temperature
Sites of bleeding
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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

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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

p
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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
Notify Medical
Direction

Courtesy of David
Effron, M.D.

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 prehospital 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