The Polytrauma Patient

Dr Neville Muhumuza

21/04/2024
Injury??
• M- Mechanism of Injury ( what happened )
• I- Injury sustained or suspected
• S – Vital signs on injury
• place and during evacuation
• T – Treatment initiated
Objectives
• Definition of an Injured Pt
• Common causes of Injury
• Identify correct sequence of priorities of assessing multiple
injured patient
• Apply principles ATLS Primary survey
• Apply Principles of Secondary survey of ATLS
• Managemeny of injured patient
The burden of injuries

• Injury accounts for 10% of the global burden of disease

• 90% of this occurs in LMIC

• 100 million temporarily and 40 million permanently injured @ year.

• Over 5 million people each year succumb to a form of injury

• There are disparities of this burden by region.

• A 24-hr survey in 105 regional and district hospitals.
• 100% response rate
• Of 5227 patients seen, 508 (9.7%) presented with trauma related
complaints.
Patterns of injuries
• Primary injury
• At time of impact

• Secondary injury
• Hypoxia
• Hypotension
• Increases ICP
• Poor/delayed treatment of primary injury
 Time-line principle

• Overall interventions
to a trauma patient
should be instituted in
a timely manner
 Trauma Deaths
Immediate

Early:

Delayed:
Trauma death – causes
“TIME IS ESSENCE”

The Golden hour

• The best chance of survival occurs when seriously

injured patient has emergency management within ONE
hour of the injury.
 GOLDEN HOUR

Right patient

..to the Right facility

..at Right time

Pathophysiology of polytrauma
Management of a polytrauma
patient.
PRINCIPLES OF MANAGEMENT IN
TRAUMA
• Organized team approach
• Complexity of injuries
• Assumption of most serious injury
• Treatment before diagnosis
• Thorough examination
• Missed injuries in unconscious patients
• Frequent assessment
• Lead to prompt corrective actions
• Primary Survey & Resuscitation

• Secondary Survey

• Definitive Care
 Advance Trauma Life Support (ATLS
)
This is the series of very urgent management to a life
threatening traumatized patient which preceeds general
examination of the patient. It has two steps
• 1. Primary survey 3 minutes
• 2. secondary survey
is detailed + involves investigations
ATLS – Primary survey
• A - Airway
• B- Breathing
• C - Circulation
• D - Deformity
• E - Exposure
Airway
• Assessment for obstruction, foreign bodies, facial fractures, bleeding
per airway.
• Recognize impending obstruction early to prevent difficult intubation
How to assess airway
• Suction
• Oropharyngeal and nasopharyngeal
• Laryngeal mask for airway
• Definitive airway
• Avoid risk of aspiration, impending obstruction
Breathing assessment
• Inspection
• Auscultation
• Palpation
• Percussion
• Assess chest movements
• Identify and manage life threat injures.
• Chest injury ( massive hemothorax, open pneumothorax, flail chest,

• Maneurves
• Bag and mask ventilation
• Need thoracocentesis
• Chest tube intubation
Circulation
• Assessment if the injured patient, if there is signs of bleeding classify
the patient according to ATLS classification of hemorrhagic shock
…Estimate the blood loss on initial presentation of pt
ATLS classification of hemorrhagic shock + Mgt
Fluid resuscitation - DEBATE

Sho
ck
due
hae to p
Fir m or r h r i m a
st a g ry
Hit e On
goi
resu ng Coagulopathy
Sec scit blee
d
ond ation r ing 2 O
Hit egi
? meLethal
n
Voluminous crystalloid Triad of
● dilutes coagulation factors
● causes hyperchloremic and lactate Death
acidosis Hypothermia Acidosis
● supplies inadequate O2 to under-
perfused tissue
 Balanced resuscitation
1. Fluid Replacement in Balanced Resuscitation
● Initial fluid replacement with up to 2L crystalloid
Permissive hypotension to achieve SBP to 80-90mmHg (radial pulse) until definitive
control of bleeding is obtained
● Role of fluid challenge (250-500ml) tests to stratify responder, transient responder,
non-responder

2. Haemostatic Resuscitation
● Early blood versus HBOC transfusion decreases MODS
● Packed RBC, FFP and Platelets in 1:1:1 ratio
● Cryoprecipitate, Tranexamic acid, Recombinant factor-VIIa
● Storage blood of < 2 weeks to minimise TRALI, MODS
Disability
• Glascow Coma Scale
• Pupil reaction and size
+
Glucose level
Exposure
• Undress the patient completely but prevent hypothermia
• Logrolling and looking for back and spine
Important while doing Primary
Survey
• ECG
• Pulse oximetry
• Xray chest + pelvis
• Urinary Catheter
• Gastric Catheter
• Blood pressure
• Arterial blood gases
• FAST
Secondary survey
• It starts after primary survey, resuscitation and vitals are normal
• Includes head to toe evaluation
• A- Allergy
• M – Medication
• P – Past medical history
• L – Last mealor other intake
• E - Event/environment leading to presentation
Important in Secondary Survey
• CT scan
• Contrast studies
• Xrays images
• Endoscopy
• Ultrasonography
Repeat evaluation while monitoring
• Re-evaluation to assure no missed injury
• Continuous monitoring of vital signs
• Effective analgesia
SPO2
• If injured patient has less than 90% of oxygen saturation administer
Oxygen 6liters /min

• Temperature is less than 36.5 degrees of centigrade, provide warm

blankets for patient, warm drinks, warm environment
Pain mgt
• Depending on the level of injury
• Standard analgesics may be used
• Some injury local or topical analgesics may be used
• If severe injury sedation may be needed
Bleeding injured pt
• If the injured patient is bleeding
• Apply pressure and dress the wound to stop bleeding
• If the injury is severe… apply mechanical toniquet and observe principles of
torquet

Consider fluid replacement

Consider blood transfusion depending class of shock

Tetanus Toxicoids are indicated to any open injury

Guidelines for TT is considered
Injured patient… if suspected to
have fracture
• Apply splint, extending from one joint below to one joint above the
fractured site

• And pain management medications should be prescribed

Medication; DON’T FORGET
• Tetanus prophylaxis

• Anti D immunoglobulin in possible preg female

• Steroids

• Inotrophic drugs

• Antiobiotics

• Calcium gluconate

• Bicarbonate
Endpoint of resuscitation
What is adequate resuscitation.

• urine output 0.5-1.0 ml/kg/hr (30 cc/hr)

• serum lactate levels : normal < 2.5 mmol/L, < 45 mg/dL

• most sensitive indicator as to whether some circulatory beds
remain inadequately perfused

• gastric mucosal (ph >7.3)

• base deficit (normal -2 to +2)

Beyond the first hour
• Polytrauma patients:
The term “polytrauma” has been frequently defined in terms of a
high Injury Severity Score (ISS) and has been generally used
interchangeably with terms such as “severely injured” or “multiple
trauma

The internationally accepted threshold of an ISS ≥ 16 is based on the

description as being predictive of a mortality risk above 10%
New Injury Severity Score (NISS)

• It classifies injured by scoring system to be based on anatomic criteria

NISS
• Abbreviated Injury Scale (AIS) grades
• 0 - no injury
• 1 - minor
• 2 - moderate
• 3 - severe (not life-threatening)
• 4 - severe (life-threatening, survival probable)
• 5 - severe (critical, survival uncertain)
• 6 - maximal, possibly fatal
• NISS = A2 + B2 + C2, scores range from 1 to 75
• A,b,c takes three highest scores regardless of anatomic area
• single score of 6 on any AIS region results in automatic score of 75
Damage control

• The principle of damage control surgery was first proposed in the

context of general surgical trauma in 1993.

• The principle is to address major injuries first before transfer to

intensive care for stabilization when definitive surgery can be
managed
Phases of damage control

1. Acute phase: life-saving procedures are performed.

2. Second phase: control of hemorrhage, the temporary stabilization

of major skeletal fractures, management of soft tissue injuries,
while minimizing the degree of surgical insult to the patient.

3. Phase three: monitoring period in ICU,

4. Phase four: focuses on definitive fracture fixation

Factors grading clinical status in
polytrauma
• Stable

• Borderline

• Unstable

• Extrimis

If patient meets the criteria in 3/ 4.

DCO vs ETC

• DCO is done in unstable and extrimis patients

• ETC (Early total care ) is the gold standard in stable patients.

 Other parameters to guide DCO
• ISS >40 (without thoracic •bilateral femoral fractures
trauma) •pulmonary contusion noted
• ISS >20 with thoracic
on radiographs
trauma
•hypothermia <35 degrees C
• GCS of 8 or below

• multiple injuries with severe

•head injury with AIS of 3 or
pelvic/abdominal trauma greater
and hemorrhagic shock
•IL-6 values above 500pg/dL
What about borderline patients?
Only life threatening injuries should be
treated
• unstable pelvic fracture

• compartment syndrome

• fractures with vascular injuries

• unreduced dislocations

• traumatic amputations

• unstable spine fractures

• cauda equina syndrome

• open fractures
Initially Resuscitate

• Pelvic packing , skeletal traction , binder , ex-fix

• If hemodynamically stable proceed with CT chest , abdomen, pelvis.

• If not: ex-lap, pelvic angiography and embolization

Definitive treatment

• 7-10 days for pelvic fractures

• 3 weeks for femur fractures (convert ex-fix to IMN)

• 7-10 for tibia

Early appropriate care

• Identifies major trauma patients and definitively treats the most time-
critical orthopaedic injuries while minimizing the secondary
inflammatory response, guided by laboratory parameters of adequate
resuscitation
Time to “early total care” (ETC)

• Treat definitively: spine, pelvis, femur, acetabulum within 36 hrs of injury.

• You are guided by:

• lactate of < 4.0 mmol/L

• pH ≥ 7.25

• base excess ≥ -5.5 mmol/L

Massive transfusion protocol
Various definitions of massive blood transfusion (MBT) have been
published in the medical literature such as:
• Replacement of one entire blood volume within 24 h
• Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h
• Transfusion of >20 units of PRBCs in 24 h
• Transfusion of >4 units of PRBCs in 1 h when on-going need is
foreseeable
• Replacement of 50% of total blood volume (TBV) within 3 h.
Massive transfusion protocol
Why MTP

• The primary objective of a massive transfusion is to prevent fatal

outcomes resulting from critical hypoperfusion-related complications
while striving to attain hemostasis
What does it involve?
• PRBCs, platelets, and FFP in a 1:1:1 ratio
Thank you