Management of patients with multiple trauma Prof. M K Alam MS; FRCS

ILO’s Incidence of trauma Causes and types of trauma   Timing and mode of death in trauma patients and its effect on trauma management. Pre-hospital care and triage Hospital care Primary survey and initial management Secondary survey Pathophysiology of common injuries Investigations during primary and secondary survey A brief outline of management of major injuries.

Epidemiology Trauma remains the most common cause of death between the ages of 1 and 44 years. Affects a disproportionate number of young people- the burden to society in terms of lost productivity, premature death, and disability is considerable. A major public health issue.

Arab News 16th Feb 2014

Arab News 16th Feb 2014 20 deaths daily on the Kingdom's roads. Last year- 707 amputations due to RTA. Accidents increased by 78% in the KSA recently Affecting mostly young between 18 and 22 years Around 30% of those injured are permanently disabled. The state has spent SR21 billion treating such patients

Causes of trauma RTA or MVA Pedestrian trauma Fall from height Assault Firearm injuries Knife Industrial accidents Natural disasters Explosions

Types of trauma Blunt trauma results of an impact from blunt object Penetrating trauma results from an object piercing the body Assessment and diagnosis of blunt injuries are more difficult than of penetrating injuries Multi-trauma- injury affecting simultaneously different organ and body system

Trimodal death in trauma Immediate: Within seconds or minutes after injury- 50% of deaths due to injury to the aorta, heart, brainstem, or spinal cord or by acute respiratory distress. Early: Within hours of injury- approximately 30% of deaths. Half of these deaths are caused by hemorrhage and the other half by central nervous system (CNS) injury. These patients can be saved by appropriate treatment (golden hour). Late: peaks from days to weeks, mortality due to infection and multiple organ failure.

Improvement in mortality Early deaths: Prevention and control program by legislation and behavior modification Later deaths: Trauma centers providing better care. Better understanding of pathophysiology of multiple organ failure and brain injury

Pre-hospital care Delivery to the hospital for definitive care as rapidly as possible- scoop and run Only critical interventions at the scene Airway established, hard collar, spine board, control any external hemorrhage Infusion on way to the hospital

Triage Definition: Prioritizing victims into categories based on their severity of injury, likelihood of survival, and urgency of care. Goals: Identify high-risk injured patients who would benefit from the resources available in a trauma center. Limit the excessive transport of non-severely injured patients so that the trauma center is not overwhelmed.

Hospital care ATLS approach A well defined order Primary survey- initial assessment and management Treat the greatest threat to life Immediate intervention as the threat to life is identified Detailed history not essential Re-evaluation of initial management Secondary survey- a head to toe evaluation

Primary survey A B C D E Airway & cervical spine protection Breathing Circulation Disability (neurologic assessment) Exposure and Environmental control

Primary survey- a team approach Simultaneous diagnosis and treatment by multiple providers Reduces the time to assess and stabilize a multiple trauma patients Team should be organized before patient arrival. Leadership and unity of command are essential

Primary survey-one clinician Do not perform subsequent steps in the primary survey until after addressing life-threatening conditions in the earlier steps.

Part II

A

Airway & cervical spine Verbal response: Salam! How are you? Airway is compromised if: No response- unconscious , airway obstruction Noisy breathing Severe facial trauma Oropharyngeal bleeding or foreign body Patient agitated - hypoxia

Airway & Cervical spine Adequacy of airway- completed within seconds Open the front of the collar for airway manipulation Maintain manual stabilization by an assistant Oropharyngeal airway/ bag valve mask ventilation Oxygen supplement + pulse oximetry Rapid-sequence endotracheal intubation Frequent reassessment for airway compromise

Difficult airway Surgical airway when oral intubation cannot be accomplished: Cricothyroidotomy –Surgical Percutaneous needle technique- only temporary Tracheostomy (laryngeal injury)

B

BREATHING Life threatening injuries to look for: Tension pneumothorax Open pneumothorax (open chest wound) Flail chest with underlying pulmonary contusion Massive hemothorax

BREATHING Dyspnoea Unilateral diminished chest expansion Bruising/ abrasion Distended neck vein Trachea deviated to the opposite side Percussion: dull - haemothorax Hyper resonant - Pneumothorax Diminished/ absent breath sound

Tension pneumothorax Pathophysiology Collapsed lung acts as a one-way valve Each inhalation- additional air accumulate in the pleural space. Normal negative intrapleural pressure becomes positive, depressing the ipsilateral hemidiaphragm, pushing the mediastinal structures into the contralateral chest Contralateral lung is compressed, the heart is rotated about the superior and inferior vena cava, decreasing venous return and cardiac output while distending the neck veins

Tension pneumothorax Clinical features & treatment Respiratory distress Tracheal deviation away from the affected side Lack of or decreased breath sounds Distended neck veins or systemic hypotension Subcutaneous emphysema, hyper resonance Treatment: x-ray confirmation not required Wide bore needle in 2nd inercost. space, mid clavicular Chest tube in 5th intercost. space, ant. axillary line

Open pneumothorax or sucking chest wound Pathophysiology Full-thickness loss of the chest wall: free communication between the pleural space and the atmosphere. Collapse of the lung on the injured side If the diameter of the injury is greater than the narrowest portion of the upper airway, air will preferentially move through the injury Impair ventilation on the contralateral side

Open pneumothorax Management Complete occlusion of the injury may result in converting an open pneumothorax into a tension pneumothorax. Initial treatment: occlusive dressing, which is taped on three sides over the wound Dressing permits effective ventilation, while the untaped side allows accumulated air to escape from the pleura Definitive treatment: wound closure and tube thoracostomy

Flail chest with pulmonary contusion Pathophysiology Four or more ribs fractured in at least two locations Paradoxical movement of free-floating segment may occasionally compromise ventilation. More importantly, an underlying pulmonary contusion may compromise oxygenation or ventilation Initial chest x-ray underestimates the degree of contusion. The lesion evolve with time and fluid resuscitation.

Flail chest with pulmonary contusion Management Respiratory failure in these patients may not be immediate Frequent re-evaluation is needed. Intubation and mechanical ventilation is required

Massive hemothorax Accumulation of >1.5L of blood Disruption of large vessel Flat neck vein Dullness on percussion No breath sound Shock Management: Chest tube in 5th space, fluid resuscitation. Thoracotomy if significant bleeding continues.

Part III

C

Circulation Assessment of cardiovascular compromise and management Is the patient in shock? Any external bleeding source? Any internal hemorrhage?

Circulation Pathophysiology Shock is secondary to hemorrhage in most trauma patients Patient can be in shock before developing hypotension Hypotension- a sign of decompensation (class III ) 5 locations for major blood loss: Chest Abdomen Pelvis and retroperitoneum Multiple long bone fractures ( lower limb) External hemorrhage

Pathophysiology of blood loss Responses are compensatory Progressive vasoconstriction- skin, muscle, viscera Tachycardia to preserve cardiac output Increased peripheral resistance- catecholamines Venous return preserved in early stage by reduced blood volume in venous system Continued bleeding- shock develops Inadequate tissue perfusion, metabolic acidosis

Classes of hemorrhagic shock Class I Class II Class III Class IV Blood loss (ml) Up to 750 750- 1500 1500- 2000 > 2000 Pulse <100 >100 >120 >140 BP Normal Decreased

Circulation Indicators of shock in trauma patients Tachycardia* Agitation Tachypnea Sweating Cool extremities Weak peripheral pulse Decreased pulse pressure Hypotension Oliguria

Circulation Cardiogenic shock Tension pneumothorax- most common cause, Pericardial tamponade(penetrating trauma), Myocardial contusion Beck’s triad- hypotension, distended neck vein (raised CVP >15 cm H2O), muffled heart sound CVP: Hemorrhagic <5 cmH2O Dysrhythmias in contusion Ultrasonography : helpful in diagnosis Treatment: fluid resuscitation, pericardiocentesis

Circulation Neurogenic shock Loss of sympathetic tone due to cord injury Hypotension, warm well perfused limbs, diminished/absent motor function Bradycardia Management: IV fluid, vasopressor, corticosteroids

Circulation Septic shock Delayed arrival Penetrating abdominal injuries Early septic shock- normal circulating volume Tachycardia Warm skin Systolic close to normal, Wide pulse pressure

Circulation Initial management External haemorrhage- compression dressing IV access- two peripheral catheters ECG monitoring Blood sample- typing and lab. investigations Initial resuscitation:1-2L of Ringer's lactate or NS Packed red blood cells if no response Foley’s catheter: urine output is .5 mL/kg/hour in adult

Circulation Initial management Search for any source of blood loss: CXR, X-ray pelvis, FAST (focused abdominal sonography in trauma) If fracture pelvis is found pneumatic antishock garment or a bed sheet wrapped around the pelvis may be applied

Evaluation of fluid resuscitation BP and pulse rate Urine output (0.5ml/kg/hour) Mental status and skin color/temperature CVP Acid/base status

Management decisions Rapid responders Hemodynamics return to normal after fluid resuscitation Hemodynamics remain stable even after reducing infusion to maintenance rate. Probably bleeding has stopped spontaneously Continued evaluation for source of bleeding May still need surgery

Management decisions Transient responders Decompensate once fluid resuscitation is slowed down There is ongoing bleeding or inadequate resuscitation Increase fluid resuscitation and blood transfusion (type specific or O negative) ?Surgical intervention

Management decisions Non-responders Fail to respond to fluid and blood resuscitation Major blood loss (>40%) & ongoing loss Immediate surgical intervention ? Non-hemorrhagic shock (cardiogenic) Echocardiography CVP

Part IV

D

Disability Neurologic evaluation Level of consciousness measured by the Glasgow Coma Scale (GCS) If the GCS is used in intubated and paralyzed patients, record should be made Pupillary response can still be assessed in a paralyzed patient

Glasgow Coma Scale (GCS), Total = 15 Eye response Vocal response Motor response Spontaneous 4 Oriented 5 Obeys commands 6 To voice 3 Confused 4 Purposeful movement to pain 5 To pain 2 Inappropriate words 3 Withdraw from pain 4 None 1 Incomprehensible words 2 Flexion to pain 3 *** None 1 Extension to pain 2 None 1

Head injury severity Mild GCS ≥ 13 Moderate GCS 9- ≤ 12 Severe GCS ≤ 8

E

Exposure/ Environment control Completely undress the patient Perform a rapid head-to-toe examination Identify any injuries to the back, perineum, or other areas that are not easily seen in the supine position Unexpected injuries may be discovered Once assessment completed, cover the patient with blanket ( prevent cold exposure)

Secondary Survey Only after completion of primary survey(ABCDE) Life threatening injuries have been dealt Normalization of vital signs A head to toe evaluation Detailed history and examination Continuous reassessment of vital signs Additional lab. & radiological tests and collecting results Additional tubes, lines and monitoring devices Priorities and plan definitive management of all injuries

Head injury Traumatic brain injury (TBI)- the leading cause of death in trauma patients- 50% of all traumatic deaths. Primary injury- the anatomic and physiologic disruption that occurs as a direct result of trauma Secondary injury- extension of the primary injury, result from local swelling, increased ICP, hypoperfusion, hypoxemia, or other factors. Aim- detection and treatment of primary injury and prevention of secondary injury

Head injury- management Maintain BP >90 mmHg, PaO2 >60 mmHg Assess GCS and lateralizing signs- pupil and motor function Pupillary asymmetry >1 mm suggests intracranial injury Larger pupil is on the side of the mass lesion Extremity weakness- detected by testing motor power CT scan head- accurate localization of the lesion Epidural or subdural hematoma causing mass effect evacuated Diffuse axonal injury- maintain cerebral perfusion and prevent rise in ICP

Spinal cord injuries Intensive hospital care, long-term rehabilitation, life-long care. Initial care- strict immobilization of the spine Complete neurologic assessment Steroid therapy must be initiated within a few hours of injury Injuries above C3- are apneic, need intubation between C3 and C5 – may need intubation later Complete transection- poor prognosis Preservation of remaining function

Thoracic injuries Life-threatening : tension pneumothorax, massive hemothorax, open pneumothorax, flail chest, and cardiac tamponade Rib fractures, sternal fracture, lung contusion, Injuries to trachea, bronchi, heart, diaphragm, esophagus, thoracic aorta Diagnostic modalities: CXR, ultrasonography, chest CT, esophagography, esophagoscopy, bronchoscopy, and angiography

Part V

Abdominal injuries 25% of all trauma victims require abdominal exploration. Physical examination- inadequate to identify intra-abdominal injuries Diagnostic modalities- CXR, FAST, DPL,CT & laparoscopy Blunt trauma: Hemodynamically stable- CT scan , Hemodynamically unstable- FAST

Diagnostic peritoneal lavage (DPL) Insert catheter below umbilicus under LA and full asepsis and saline (1L NS) infusion into peritoneum Returning fluid is bloody- +ve lavage Rapid and safe Bloody aspirate- laparotomy Do not determine origin of blood Too sensitive Does not evaluate retroperitoneal injury Replaced by FAST and CT scan

FAST- focused abdominal sonography in trauma Superseded DPL in assessment of abdominal trauma 98% sensitivity for hemoperitoneum

Abdominal injuries (penetrating) All gun shot injuries- urgent surgery Stab (knife) injury: Hemodynamically stable- CT scan, surgery only if intra-abdominal injuries found Hemodynamically unstable- surgery

Splenic injury Most frequently injured in blunt trauma (personal series) History of injury to the left side of the chest, flank, or left upper part of the abdomen Bruising, pain tenderness- lower chest and upper abdomen on left side Diagnosis- CT in hemodynamically stable patients FAST or exploratory laparotomy in an unstable patients

Splenic injury Non-surgical management (70%) Hemodynamically stable patients: FAST, CT for diagnosis No other intra-abdominal injury requiring operation Admission to ICU for continuous monitoring Serial Hb. , & repeated abdominal assessment If hypotension develops - taken for surgery

Splenic injury Surgical management Hemodynamically unstable FAST: splenic injury, free fluid (hemoperitoneum) Surgery- splenectomy Polyvalent pneumococcal vaccine (pneumovax)

Liver injury- pathophysiology Susceptible to injury due to large size(1200-1600 g) Covered by bony thoracic cage Injury frequency - only 2nd after spleen( personal series) Highly vascular- only 4% of body weight but 28% of total body blood flow Double blood supply- portal vein & hepatic artery Draining hepatic veins- short and thin walled

Liver injury Spontaneous hemostasis- 50% of small lacerations Profuse bleeding from deep hepatic lacerations- a formidable challenge Mortality rate 8%- 10%, morbidity rate from 18%-30%, Diagnosis: FAST in hemodynamically unstable, CT scan in hemodynamically stable Management based on hemodynamic status

Liver injury Non-operative management Hemodynamically stable patients CT scan No other indications for abdominal exploration ICU admission for close observation Serial hemoglobin estimation Transfusion requirements of <2 units of blood Surgery- if become unstable

Liver injury Surgical management Principles of surgical management: control of bleeding, removal of devitalized tissue, and adequate drainage. Bleeding vessels & biliary radicles are individually ligated Pringle’s maneuver Perihepatic packing- when fail to control hemorrhage Packs removed in 48 hours

Pancreatic injuries Pancreatic injury is rare Caused by penetrating injury or direct blow Diagnosis is difficult to make CT scan, elevated serum amylase may help No duct injury: simple drainage Ductal injury: distal resection

Bowel injuries Mostly due to penetrating trauma Also seen after blunt trauma Features of peritonitis CT scan free air in peritoneum/ contrast leak Small bowel: Suture repair Colon: suture repair± proximal colostomy

Renal injuries Minor- renal contusion (85%) Conservative management Major: Deep medullary injuries with extravasation Vascular injuries Surgical repair

Thank you!

Part VI

Case for discussion

An ambulance is bringing a young man who was riding a motor bike An ambulance is bringing a young man who was riding a motor bike. He was thrown from the speeding motor bike on a bending road. He was not wearing a safety helmet. His left leg appears grossly deformed. The ambulance has informed ER before bringing him. You are the only doctor in ER What to do?

Preparation before patient arrival Airway equipment, cervical collar, pulse oximetry, ECG monitor, oxygen Laryngoscope, Needles, chest tubes, under-water seal, Minor op. set, local anaesthetic, IV fluids at room temp. Blood sample tubes Splints Radiologist and technician Foley catheter and urine bag

Management in a hospital Patient arrives in hospital Patient is on a spinal board Deformed left lower limb with blood stain on cloth? What to do next?

Primary survey A B C D E

Assessment of airway Talk to the patient Danger signs Not talking Oro-facial bleeding Confused Agitated Neck hematoma

Airway management Clearing oral cavity Oropharyngeal / bag valve mask Chin lift / jaw thrust Oral endotracheal intubation Surgical methods Adjuncts: oximetry, oxygen Cervical collar if not applied during transport Manual in-line support by an assistant

Breathing Patient continues to be dyspnoeic? Oxygen saturation not improving? Chest injuries to look for and manage Tension pneumothorax Massive hemothorax Flail chest Open chest wound pO2 and respiratory rate improves

Circulation Pulse, BP,RR Any external bleeding? Look at his deformed limb 2 IV line, blood samples RL or NS 1-2 L as bolus rapidly Quick response: slow down iv to maintenance Transient response: BT ?bleeding No response: ?Major bleeding ? Inadequate resuss. ?non- hemorrhagic shock ( cardiogenic, spinal, septic)

Hemorrhagic vs Non-hemorrhagic shock Neck vein Pulse (rhythm, volume, rate) Heart sound ECG CVP Later : Spinal injury Late presentation with abdominal injury

Major bleeding sources Chest: massive hemothorax Abdomen: hemoperitoneum Pelvis: pelvic & retroperitoneal hematoma Lower limb fractures

Investigations for bleeding source CXR* FAST DPL CT X-ray pelvis* *X-ray c spine- the only other x-ray allowed during Primary survey

Disability & Exposure GCS Full exposure including the blood mark on his lower limb. Splint the limb- if not already done during assessment for external hemorrhage Cover patient with a blanket Reassess ABCD

Secondary survey Only after completion of primary survey(ABCDE) Life threatening injuries have been dealt Normalization of vital signs A head to toe evaluation Detailed history and examination Continuous reassessment of vital signs Additional lab. & radiological tests and collecting results Additional tubes, lines and monitoring devices Priorities and plan definitive management of all injuries

Thank you!