Management Of Multiply Injured Patients By: Dr. Zuhair Al-Samarrae FRCS, FICS, CABS, DS, MBCHB

TRAUMA DEATHS SINCE MIDNIGHT 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 DEATHS SINCE MIDNIGHT                    

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?

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

prioritization Triaging according to : Salvagability: Donot waste time on unsalvagable cases Severity of injury(ABCDE): Donot waste time on <life threatening injuries

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

Spicy pizza in hospital Do Primary Survey-minutes only What is primary survey? ABCDE Talk to the victim:a verbal response means a patent airway and reasonable breathing. If no verbal reponse then The Pizza Indian spicy&v. hot

ABCDE Airway and C–spine immobilization Breathing Circulation Disability Exposure / Environment control

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

airway Oro&nasopharyngeal airway Suction Removal of denture ,FB… Ambu-bag Endotracheal intubation, LMA Cricothyrotomy C-spine immobilization In short: maintain the airway

Breathing 4 conditions need to be recognized-treated Tension pneumothorax Open pneumothrax Flial chest Massive hemothorax The good news is--- u need 2 tubes&1 needle and mask Most life-threatening thoracic injuries can be treated by airway control, needle/chest tube insertion

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

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 anywhere—do I need to know the exact anatomical source? Not really ….early management is the same.

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

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

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.

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 ?

Adjuncts to primary survey X-ray chest & pelvis - + C-spine Pulse-ox ECG monitoring NGT. Urinary catheter.

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…

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

Almond Board of California Remember Never forget your ABC…what is ABC? Almond Board of California