Management Of Multiply Injured Patients

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Management Of Multiply Injured Patients

• By
• Dr. Zuhair Al-Samarrae
• FRCS, FICS, CABS, DS, MBCHB

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Trauma

• Trauma claims the life of millions every year.
• Mostly it affects young age group-the productive
  section of society.
• Visit Trauma.org and look at the instantly
  changing no.of mortality due to trauma.

TIME NOW                   TRAUMA
DEATHSSINCE MIDNIGHT                    
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TIME OF ESSENCE

• What are areas where time is wasted?
• Trimodal death and the Golden Hour
• 3 peaks of death
• 1st peak-seconds to minutes after injury-due to
  brain lacerations,rupture aorta.
• 2nd peak minutes to hours after injury-the peak
  of avoidable death-the golden Hour
• 3rd peak in ICU-due to sepsis, MOD..
• WHERE DO U PUT YOUR MONEY?

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Time of essence

• Yes exactly
• It is in the Golden Hour
• So again where is waste of time usuallly occur?
• 1.in the field Scoop and run
• not stay and play
• 2.in hospital be prepared
• mobilize Trauma Team

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prioritization

• Triaging according to
• Salvagability Donot waste time on unsalvagable
  cases
• Severity of injury(ABCDE) Donot waste time on
  ltlife threatening injuries

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Spicy Pizza

• Ensure your safety and yor team
• Triage multiple casualities
• Prioritize (ABCDE)manage accordingly
• Notify the hospital
• Scoop and run

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Spicy pizza in hospital

• Do Primary Survey-minutes only
• What is primary survey? ABCDE
• Talk to the victima verbal response means
• a patent airway and reasonable breathing.
• If no verbal reponse then
• The Pizza Indian spicyv. hot

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ABCDE

• Airway and Cspine immobilization
• Breathing
• Circulation
• Disability
• Exposure / Environment control

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ABCDE

• Open the airway chin lift jaw thrust
• No head tilt
• No hyperextension
• No hyperflexion
• No rotation
• But maintain on-line immobilization
• May need adjuncts

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airway

• Oronasopharyngeal airway
• Suction
• Removal of denture ,FB
• Ambu-bag
• Endotracheal intubation, LMA
• Cricothyrotomy
• C-spine immobilization
• In short maintain the airway

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Breathing

• 4 conditions need to be recognized-treated
• Tension pneumothorax
• Open pneumothrax
• Flial chest
• Massive hemothorax
• The good news is---
• u need 2 tubes1 needle and mask
• Most life-threatening thoracic injuries can be
  treated by airway control, needle/chest tube
  insertion

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Thoracic injuries

• Inspect---close an open pneumoth.
• Palpate flial chest may need intubation?
• Percuss auscultate
• needle for tension pneumoth ---tube for massive
  hemothorax ?
• Blood R/L solution.
• Again u need 2 tubes,needle,and mask

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Circulation -SHOCK

• Bleeding is the predominant cause of death.
• Shock recognition
• pulse, skin color , level of conciousness.
• Pulse rate. Volume and regularity.
• Bp -----late
• Anatomical vs physiological derangement
• These changes occur with bleeding anywheredo I
  need to know the exact anatomical source?
• Not really .early management is the same.

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Hemorragic shock-management

• Support circulation and stop bleeding.
• Support circulation 2 wide bore cannula
• 2L warmed R/L ,
  blood
• Avoid hypothermia---risk of coagulopathy.
• Stop bleeding
• stop external bleeding by direct pressure
• How about torniquet ?
• Only in bleeding amputated limb
• Splint fracture e.g pelvic fracture

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TRANSIENT RESPONSE---WHY?

• Ongoing bleed.or may be ..???
• Other causes of shock-- obstructive shock
• Obstructive e.g tension pneumothorax tamponade
  (treated by pericardiocentesis)
• Keep an eye open to other possibilities?
• Neurogenic shock IVF - vasopressors.
• Periodic re-evaluation esp indeterioration

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D - Disability

• GCS or AVPU
• GCS 3-15 3 worst, and 15 best
• What can cause abnormal GCS?
• Of course brain injury, but what else?
• Hypotension and hypoxia.
• Any deterioration of GCS is due to brain
  injury----check pulse-ox vitals 1st .
• Always assume spinal injury , so immobilize
  spines--- cervical collar backboard.

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E ----Exposure Environment control

• Exposure is nessary for proper assessment, and to
  avoid missing injuries
• Avoid unnecessary exposure
• Warmed IVF
• Warm blankets
• Raise room temperature.
• Any relation between E C ?

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Adjuncts to primary survey

• X-ray chest pelvis - C-spine
• Pulse-ox
• ECG monitoring
• NGT.
• Urinary catheter.

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END OF PRIMARY SURVEY

• WHAT NOW?
• Consider transfer( remember time) next?
• Secondary survey head- toe examination
• Re-evaluate and re-evaluate
• Re-evaluate .
• Re-evaluate

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summary

• Time of essssssence
• Triage according to salvagability
• Prioritize according to ABCDE
• Early Recognition,Early intervention,Early
  transfer-scoop and run

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Remember

• Never forget your ABCwhat is ABC?
• Almond Board of California