Polytrauma 1st Dpt. Of Surgery University hospital of St. Anne Faculty of Medicine Masaryk University Brno What are the causes of death? 1. 2. 3. Cardiovascular disease (IHD, strokes) 52% Tumors 26% Trauma(external causes) 7% a. Traffic, work, sports, home, industrial, criminal BUT !!!! ★ ● Trauma under 40y ........ 1st place ! Polytrauma Injury of 2+ organ systems and at least one of them is life threating • Active approach of diagnostics and treatment • Co - operation • Centralisation • • Body regions and injured systems: ● ● ● ● ● ● Head, neck, and cervical spine Face Chest and thoracic spine Abdomen and lumbar spine Limbs and bony pelvis External (skin) ● ● ● ● ● ● ● • Limbs 90% Skull and brain 72% Chest 53% Abdomen 29% Pelvis 24% Spine 10% Heart&vessels 10% Polytrauma High energetic trauma ● 3R rule: right patient, right hospital, right time ● ● scoring systems: prediction of injuries and survival ● Glasgow coma scale ● Abbreviated injury scale (AIS) ● Injury severity score (ISS) ● AO classification Tscherne, Gustillo-Anderson ● ISS skóre Field triage - ATLS ● Mechanism of injury ○ Falls > 6 meters (second floor) ○ High risk auto crash (ejection, intrusion, death of another passenger, telemetry) ○ Motorcycle crash > 30 km/h ○ ● Auto vs. pedestrian/bicyclist > 30 km/h Consider special conditions ○ Age < 6y or > 55y ○ Cardiopulmonar comorbidity ○ Pregnancy ○ etc ● Vital signs and level of consciousness ○ ○ ○ ● GCS < 13 Systolic blood pressure < 90 Respiratory rate < 10 or > 29 (or need for ventilatory support) Anatomy of injury ○ ○ ○ ○ ○ ○ • ○ All penetrating injuries Pelvic fractures Two or more proximal longbone fractures Crushed, degloved, mangled, or pulseless extremity Amputation proximal to wrist or ankle Open or depressed skull fracture Paralysis What will kill your patient Hemorrhagic shock • Any other shock • Bacterial contaminantion • imunosupression • Lethal triad • SIRS…MODS…MOF • Approach to polytraumatized patient Pre-hospital care (pre-medical, technical, medical) Transport to the trauma center Damage control Definitive treatment Management of polytrauma Primary survey /ABCDE/- ATLS principles • Resuscitation • Secondary survey • DCS, DCO • Stabilisation of patient • Definitive treatment • Airway + C-spine protection Obstuction • (foreign body, blood vomit, tongue, fracture, outter compression…) Maneuvers - chin lift, jaw thrust, NO head tilt!!! • Succion, airways, SGD, OTI, NTI, surgery • C spine control- neck collar, head blocks, manual imobilization • GCS 8 nad less… intubate! • Manual maneuvers Airway management No1. Airway - nasal, oral Combitube Laryngeal mask Airway management No.2 – endotracheal intubation If everything else fails.... But cricothyreotomy is faster!!! Cricothyreotomy emergency kit C-spine control Ideal C spine protection Spine board, Vacuum SB Breathing PNO, hemotorax • Fractured sternum, ribs, scapulla, collar bone • Diaphragmatic rupture • Flair chest • aspiration • Deliver oxygen via BMV!!! Circulation Identify & stop bleeding • „Blood on the floor, 4 places more!“ Replacement of intravascular volume • • 1st - crystaloids, blood derivates, coloids??, vasopressors Blood replacement protocol (4EBR:4FFP:1TRO + 1Exacyl+4g Fibrinogen) • Permissive hypotension • Minimum 2 strong IV caths!!! • Intraosseal entry – tibia, ankle, humerus • Urinary output – GOAL - 1ml/kg/hour • • Disability GCS, pupils, liquorrhea, battle sign, racoon eyes • Agitation, confussion, pain, emotional reaction • Drugs, alcohol, medication • Pain management after ABCD!!!! • Battle´s sign & Racoon eyes Exposure, enviroment Undress your patient for secondary survey • Warming up your patient • Blanket, IV fluids • • LOCK ROLL !!! 3-4 persons • Garther all the informations possible!!! Allergies • ● ● • Mechanism Injury found and suspected Medication • Previous medical history • ● Signs, symptoms • Last meal ● Treatment initiated • Events related to injury Lab Hb, Leu, Tro, Ery, coagulation, ROTEM - bed side • Basic biochem. • Blood group type, EBR, ČMP reserve • Toxicology? • Alcohol level in blood (legal issues) • FAST Focused assesment sonography for trauma • Quick orientation- free fluid, no details required • Repetitive, non-invasive, bed side • Both hemithoraces, abdominal cavity, pelvis • +/- pericardial sack • X- ray Chest X-ray • pelvis • According to today´s protocol not needed • Replaceble by clinical examination • Majority of patients get CT scan • Bones – NOOO!!! Time for that!!! • CT polytrauma protocol Only for hemodynamic stabile and secured patient!!!! • Golden standart • Nativ, IV. contrast - art., ven. phase • Alergies?? (AMPLE) • Radiologist at the place!!! • Decision making: Stabile ... FAST negat. …. CT… next… • Stabilní…FAST positive ….still stabile…CT… next… • Non-stabile… FAST positive…. surgery • Non-stabile…. FAST negat. ….??? • Urgent life-saving procedures 1. ABC 2. tension pneumothorax 3. hearth tamponade 4. Massive PNO, hemothorax 5. stabilisation of long bone/hip fractures 6. urgent laparotomy for major bleeding ?? 7. Skeletal extension reduces bleeding, reduces pain, stabilizes fracture Pelvic binder Pelvic C- clamp Damage control surgery „Easy“ and fast life-saving surgical procedures • Not reconstructions!!! • „golden hour“ rule, „Life before limb“ policy • Identifying priorities: • Stop bleeding (ektomy, tamponade, packing) • Decontamination (resections, staplers) • Fracture stabilisation (external fixation) • Why should I take care of fractures? It is not life-threating, right? Packing/tamponade External fixator - Pelvis Damage control Resustitation / surgery / orthopedics ● ● ● DCR: Analgosedation, OTI + ventilation, volume therapy (TU, FFP, crystaloids/coloids) DCS: time-limited (max 90´) ○ Control of bleeding, contamination DCO: Stabilization of long bone fractures (pelvic fractures) - external fixator ● ● ● ● return to operating room after stabilisation on ICU Death following polytrauma (Trimmodal distribution curve) 1. Immediate death (on sceen) - 50-60% ○ 2. 3. Lethal injuries Early death - 30% ○ Within hours after admision (max. 24 hours) ○ Potentially reversible (disruption of airways, blood loss) Late death - 10-20% ○ ○ ○ days to weeks after injury ARDS, sepsis, MOF, PE Potentially reversible Take home message Mechanism of injury – suspected trauma • Triage signs, scoring systems • Multiplex approach, centralization • ATLS principles – ABCDE • • O2 delivery to vital tissues Damage control surgery • Disaster Management Needs of patients overextend or overwhelm the resources needed to care for them ● Emergency preparedness ● Anticipation and readiness ● ● Multiple casualty incidents ● Mass casualty events ● Terms and terminology Acute care, acute care specialists – Emergency medical services ● „Hot zone“ - SaR, „Warm zone“ – area of operations, external perimeter ● Casualty collection point ● Decomtamination corridor (CBRNE, HazMat) ● Operation center, Incident command ● Surge capability – extra assets that can be accually deployed ● Hospital incident command system /Americas/ Emergo train systém /Europe, Australasia/ Operation center, Incident command- ● and vertical relations horizontal Emergency responders ● Triage ● Personal protective equipment ● Ways of transport, delivering material help, evacuation of victims and casualties ● ● Phases The need (ATLS, B-ATLS…) ● The approach - to do the greatest good for the greatest numbers ● Disaster management ● 1. Preparation /community, hospital, departmental, personal/ 2. Mitigation /emergency op. Centers, HICSm ETS/, SAR,WZ,CCP, EP, transport/ 3. Response /pre-hospital care, in-hospital care/ 4. Recovery Decontamination!!! PPE ● HazMat technicians ● Primary vs- secondary ● ● „Dilution is the solution to pollution“ ●