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

3. 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.

4. 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.

5. Arab News 16th Feb 2014

6. 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

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

8. 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

9. 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.

10. 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

11. 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

12. 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.

13. 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

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

15. 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

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

17. Part II

18. A

19. 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

20. 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

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

23. B

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

25. 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

27. 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

28. 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

30. 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

31. 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

32. 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.

34. 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

35. 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.

38. Part III

39. C

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

41. 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

42. 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

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

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

45. 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

46. 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

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

48. 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

49. 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

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

51. 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

52. 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

53. 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

54. Part IV

55. D

56. 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

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

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

59. E

60. 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)

61. 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

62. 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

63. 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

65. 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

66. 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

71. Part V

72. 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

73. 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

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

75. 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

76. 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

79. 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

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

81. Liver injury- pathophysiology
Susceptible to injury due to large size( 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

82. 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

85. 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

88. 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

92. 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

94. 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

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

96. Thank you!

97. Part VI

98. Case for discussion

99. 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?

100. 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

101. 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?

102. Primary survey A B C D E

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

104. 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

105. 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

106. 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)

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

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

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

110. 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

111. 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

112. Thank you!