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IN HOSPITAL CARE OF POLY TRAUMA

Dr.T.S.Srinath Kumar MD(Accident & Emergency Medicine)

Consultant & Course Coordinator

Department of Emergency Medicine,

Narayana Health – Multispeciality Hospital, Bommasandra, Bangalore

Introduction

Dealing with a victim of trauma, predominantly is the mainstay of an emergency

physician.Approach to a trauma victim requires time bound decisions, organised approach and
defining priorities in initial few minutes, these are essential for proper resuscitation and
productive out come of a critically injured patient.

Principles of Trauma Management

• Organized team approach

• Priorities in resuscitation

• Thorough examination

• Frequent reassessment

• Monitoring

Spectrum of trauma is wide,motor vehicle accidents, fire arm and ballistic injuries, fall from height
,suicidal and homicidal and burns are some of common emergencies

Mortality due to trauma

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Death of a trauma victim, occurs in one of the three periods from time of event .

First Peak : Seconds to minutes of event where death generally results from brain or spinal
injuries,or laceration of aorta and major blood vessels,very few are patients can be salvaged as
death occurs before help can reach.

Second Peak : Minutes to hours of event,where death occurs due to injuries like
pneumothorax,liver laceration,pelvic fracturs or injuries and fractures associated with significant
blood loss, also brain injuries like subdural and epidural injuries

Pneumothorax Major fractures Organ laceration

Its is this period from the event,in which a trauma victim can be salvaged by rapid assessment and
resuscitation ,this period is characterized as golden hour of care.

Third Peak : Days to weeks after the event, where patients die mostly due to multiple organ
failure,sepsis. This stress upon that organized care of trauma victim is essential during preceding
period for productive out come.

Wound infection,sepsis.

Priorities in resuscitation

Primary survey & Resuscitation

Secondary survey

Definitive care
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Primary survey

 Airway with cervical spine protection.

 Breathing and Ventilation
 Circulation with hemorrhage control
 Disability / neurological status
 Exposure / environmental control
Airway with cervical spine protection

The airway is the first priority,time is always critical as Brain begins to die within minutes.

It is essential to open airway,which may be blocked by tongue fall and also to recognize
patency of airway. In trauma victim C-spine injury is always considered unless proved
otherwise, for this reason, airways should always be opened by jaw thrust maneuver, in which
fingers are placed under the mandible and then gently lifted upwards to bring chin
anterior,the thumb of the same hand gently depresses the lower lip to open mouth. Then
cervical collar placed to stabilize spine

Once the airway has been opened,it should the cleared of any blood ,vomitus, saliva by suctioning
and if any foreging body or broken tooth are found in airway the can be removed with help of
magill’s forceps,in unconcious patients patency can be mantained by oropharyngeal airway

Clear blood,vomitus hard tip suction catheter magill’s forcep oropharyngeal

airway

Endo tracheal intubation is definite measure to protect airway ,patients with GLASGOW COMA
SCALE of 8 or less require definitive airway ,inline stabilization of the spine C-spine should be
maintained while intubating patient.

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 manual inline stabilization C-spine

If difficult airway is anticipated or failed airway occurs ,laryngeal mask airway or combitube
should the kept ready,to temporarily secure airway and immediately surgical airway should be
established.

Breathing and Ventilation

It is essential to ensure adequate ventilation that maximizes oxygenation and CO2

elemination,stepwise assessment of lungs ,chest wall and diaphragm should be made by exposing
the chest.Adequate rate and depth of respiration is must for effective ventilation,if patient is
breathing on own provide oxygen by non rebreathing mask,and if rate and depth is inadequate
,bag mask ventilation maintaining a god seal on mouth by E-C techniques should be initiated.

Non rebreathing mask E-C technique for good mouth seal

While bag ventilation is being done ,pressure on cricoid should be made to prevent aspiration due
to regurgitation of gastic contents

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Air entry in both the lung feilds should the checked immediately, and if decreased or absent air
entry is observed immediate chest decompression is considerd.

Bagmask ventilation has a deleterious effect in patients with pneumothorax,and will produce
immediate tamponade effect.

Immediate decompression of chest with a wide bore needle 14-16 G in 2nd intercostals space in
midclavicular line should be done followed by placement of intercostals drain (ICD)

NEEDLE DCOMPRESSION INTERCOSTAL DRAIN (ICD)

Circulation with hemorrhage control

Assess circulation by feeling the peripheral pulse, gain large bore iv access 14-16 G,anticipate fluid
loss give adequate fluid, blood is best for resuscitation but is not readily available, crystalloid like
ringer lactate and collid are effective alternative hypotension following injury must be considered
to be hypovolumic in origin unless proved otherwise,a rapid thready pulse is typical of
hypovolumia other clinical signs include altered consciousness, skin color like ashen or white.
external bleeding should be controlled by pressure manual pressure on
wound.

Disability - neurological status

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Neurological ststus of the patient should be assessed, by Glasgow coma scale,also rapid
assessment of the pupils should me made for size and reactivity to light ,lateralizing sign and
spinal cord injury.

Change in level of consciousness require immediate reassessment, also narcotic, drugs, alcohol
hypoglycemia can alter patients level of consciousness.

Exposure / environmental control

The patients should be completely undressed for thorough examination,at this time for log roll
and examination of back and spine also it is convenient to perform per rectal/per vaginal
examination. Care should be take to prevent patient going in for hypothermia because of
exposure .

log roll and spine examination per rectal examination pelvic

compression/distraction

• Adjuncts to primary survey

Imaging bed side should be done ,bed side x-Ray for C-spine ,chest,Plevis should be done
,also site of tenderness or deformity of limb indicative of fractures should undergo imaging .its
necessary to perfom bed side ultrasound F.A.S.T in trauma patients

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FAST

Focused assessment sonology in trauma effectively detedts free fluid in abdomen ,and also
pericardial fluid

CT-scan of the patient should be done only after stabalization of patient ,unstable patients should
not be sifted out of ER for CT scaning

All patient be catherized to know urinary output ,ant orogastric tube should be placed.

• ABG/CBG/ECG

• Base line investigation

• HCG in women of child bearing age

Constant reavaluation of the patient is necessary

Secondary survey

this does not begin until primary survey is complete and problems faced are solved,then
only next assessment is carried on .

History should include.(AMPLE)

Allergies

Medication

Past illnesses

Last meal/LMP and Last TT

Events / Environment related to injury

Head to Toe examination

head to toe examinations should be made to identify ,any contusions,abrations,lacerations,

deformity and swelling that are evident of injury.

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The examination is conducted in a head-to-toe fashion, beginning with the scalp. Scalp lacerations
can bleed profusely. This bleeding can be controlled with plastic Raney clips that grasp the full
thickness of the scalp and galea. The tympanic membranes should be visualized to detect
hemotympanum, and the pupil examination should be repeated. If epistaxis is a problem, a
balloon-tipped urinary catheter or a nasal balloon should be inserted to provide posterior
tamponade. The examination continues over the neck and thorax. The urinary meatus, scrotum,
and perineum are inspected for the presence of blood, hematoma, or laceration.

A rectal examination is done, noting sphincter function and whether the prostate is boggy or
displaced. Rectal blood should be noted. If the prostate is normal and there is no blood at the
urethral meatus, a urinary drainage catheter can be placed in the bladder. If a urethral injury is
suspected (meatal blood present), a urethrogram should be obtained prior to passing the
catheter. If the prostate is displaced, it should be assumed that the urethra is disrupted.
Catheterization should not be attempted if the urethra is injured. The urine should be
examined for blood. If the patient is a woman of childbearing age, a pregnancy test should be
obtained. If there is vaginal bleeding, a manual and speculum examination is necessary to
identify a possible vaginal laceration in the presence of a pelvic fracture. The extremities
should be evaluated for fracture and soft tissue injury. A more thorough neurologic
examination can now be done, carefully checking motor and sensory function.

Documentation is Essential and should include

Date

Time

Place

Injuries

MLC

Definitive care

No patient leaves ER with out a plan

While transferring

• Intubation kit
• O2 cylinder
• Patent iv lines
• Monitrer
• Hand over