management of polytraumatized patients
TRANSCRIPT
Management of
polytraumatized patients
‘ The art of life Support’
BY
Hosam Mohamad Hamza, MD
Lecturer of General Surgery and Laparo-endoscopy
Minia School Of Medicine
Minia –Egypt
2016
What is trauma ?
Trauma is the study of medical problems associated with physical injury.
Trauma is the 3rd leading cause of death in people aged 1-44 years, and a leading cause of disability.
WHO data suggest that 1 in 10 deaths worldwide is a result of trauma.
Serious multi-system injuries occur in 10 -15% of (polytraumatized patients) PTP.
Magnitude of the problem?
Aetiology of trauma & Mechanism of injury
Penetrating trauma Blunt trauma
- Stabs - Gunshots - Bullets
- Motor vehicle collision (50-75%)
- Direct blows to the body (15%)
- Falling from a height (6-9%)
Causes
- Tissue tearing. - Thermal injury. - Missle injury
- Crushing: direct application of a blunt force to part of the body.
- Shearing: sudden decelerations applied across organs with fixed attachments.
- Bursting: e.g. raised intraluminal pressure by abdominal compression.
- Penetration bony injuries generate spicules causing secondary penetrating injury.
Mechanism of
injury
Trauma related mortality may be:
Late Death Early Death Immediate death
20% 30% 50% %
days or weeks 1st few hours
( golden hours)
soon or within minutes Time after injury
-Sepsis.
-Multi-organ
failure
(M.O.F.)
obstruction. Airway-
-disruption of
mechanism. breathing
failure. Circulation-
injury. brainmajor -
injury. cordhigh -
airwaymajor -
disruption.
Causes
Proper patient
follow-up.
Training about ABC
resuscitation
programs.
Community education
about trauma-
preventing programs
(seat belts, head
protection,…etc)
Prevention
Trauma-related mortality
Immediate
50%
Early
30%
Late
20%
Organized trauma team
Organized trauma system
Management of trauma
I. Trauma Team Patients with major trauma are best treated by a well-organized trauma team.
Each team member should be assigned a specific task or tasks so each of these can be performed simultaneously.
II. Trauma System Recently, many protocols were introduced for management of multi injured patients including :
ATLS → Advanced Trauma Life Support.
followed by:
ATNC → Advanced Trauma Nursing Course.
and more recently:
PHTLS → Pre-Hospital Trauma Life Support.
several techniques used to maintain life when essential body systems are not sufficiently functioning to sustain life unaided
pre-hospital care:
advanced medical care:
Advanced Trauma Life Support (A.T.L.S.)
In 1970s, an air crash lead to the death of the wife and serious injuries of the three children of James Styner; an American orthopedic surgeon. An event that had forced him to introduce a structured trauma management program which was soon adopted by The American College of Surgeons and developed the Advanced Trauma Life Support (ATLS) protocol or EMST (Early Management of Severe Trauma) as known in the UK.
Triage sift and sort
Normal clinical practice
Multiple-casualty incident
Mass casualties
Normal clinical practice: one doctor or nurse
and one patient. = Do everything possible for
every patient.
Multiple-casualty incident: one doctor and
many patients. = Triage, but still capable of
dealing with all patients.
Mass casualty: one doctor overwhelmed by
casualties. = Triage, do what you can for the
greatest number.
Sift
1. Identify those most severely injured.
then
2) identify and remove:
the dead
the slightly injured
the uninjured
Sort
Categorise the most severely injured:
Serious wounds: resuscitation and
immediate action
Second priority: need surgery but can wait
Superficial wounds: ambulatory management
Severe wounds: supportive treatment
Category I: Resuscitation and immediate
action
Patients who need urgent surgery – life-saving –
and have a good chance of recovery.
(E.g. Airway, Breathing, Circulation: tracheostomy,
haemothorax, haemorrhaging abdominal injuries, peripheral
blood vessels)
Category II: Need surgery but can wait
Patients who require surgery but not on an urgent basis.
A large number of patients will fall into this group.
(E.g. non-haemorrhaging abdominal injuries, wounds of
limbs with fractures and/or major soft tissue wounds, penetrating head wounds GCS > 8.)
Category I for Airway; Category II for debridement
Category III: Superficial wounds
(no surgery, ambulatory treatment)
Patients with wounds requiring little or no surgery.
In practice, this is a large group, including superficial wounds
managed under local anaesthesia in the emergency room or
with simple first aid measures.
Category IV: Very severe wounds (no surgery, supportive treatment)
Patients with such severe injuries that they are
unlikely to survive or would have a poor quality of
survival.
The moribund or those with multiple major injuries whose
management could be considered wasteful of scarce
resources in a mass casualty situation.
Philosophy of ATLS: “ Treat the lethal injuries first, then
re-assess and treat again ”
Components of ATLS:
Primary Survey identify what is fatal and treat it.
Secondary Survey proceed to discover all other injuries.
Definitive Care develop a definitive management plan.
Primary survey and Resuscitation
identify and treat any life threatening condition.
it must be repeated any time a patient's status changes.
Steps : (stepwise approach)
history : (AMPLE )
initiated until the airway no procedures are irway, A
securedis
Breathing
Circulation
Disability (Neurologic Dysfunction)
Exposure / Environment
Fracture
Lack of an airway is one of the few situations in medicine in which seconds count.
Regarding the airway = assess, maintain, protect and provide
* assess : a- disturbed conscious level .
b- maxillo-facial or cervical trauma.
c- vomiting.
d- nasal or oral bleeding.
* maintain:
* maintain:
* protect: clear the airway if it becomes obstructed
* provide:
Indications of endotracheal entubation (ETE) in
patients with major trauma: 1.Apnea (as part of CPR).
2.Respiratory insufficiency:
• PO2 < 60 mmHg
• PCO2 > 45 mmHg Normal PO2(adequate oxygenation)= 80-100 mmHg
Normal PCO2 (adequate ventilation)= 35-45 mmHg
3.Risk of aspiration (disturbed consciousness with repeated vomiting).
4.Impending upper airway compromise
(inhalation, maxillo- facial injuries).
5.Closed head injuries. (hyperventilation).
6. Flail chest: ????? Intubation and mechanical ventilation is rarely indicated for
chest wall injury alone. Where ventilation is necessary it is
pulmonary contusions usually for hypoxia due to underlying
Types :
-needle cricothyroidotomy
-surgical cricothyroidotomy
? Cricothyroidotomy:
more simple and faster than tracheostomy.
not suitable for children < 10 years.
needle cricothyroidotomy isn’t suitable for proper ventilation (temporary).
surgical cricothyroidotomy can be used for ventilation for only 30-45 minutes.
? Cervical spine should be considered unstable until proved otherwise by radiology (at least 3 views) esp. in:
*Altered level of consciousness.
*Blunt injury above the clavicle.
*Cervical bony abnormalities or tendernes.
*Maxillofacial trauma.
Stabilization of cervical spine:
-Backboard and rigid neck collar.
-Sand bags and fore head tape.
-If a collar is not available, manual in line immobilization is necessary.
Having a patent airway is not necessarily associated with normal respiration.
Abnormal respiration after trauma may be :
a. Central:
e.g. severe head trauma→ respiratory centre depression.
b. Peripheral (chest trauma):
Assessment of breathing : 1- Inspection :-
chest wall bulge or retraction.
chest expansion.
chest wounds.
respiratory rate .
tracheal shift.
2- Palpation :-
surgical emphysema.
tenderness.
fracture click.
flail segments.
3- Auscultation :-
air entry at different lung fields on both sides.
4- Percussion :- (less commonly used )
for hyperresonance or dullness.
5- Pulse oximetry ( ?unreliable)
6- ABG sampling
7- Chest Xray
While reading a chest X ray film, a good trauma surgeon should be a good observer …. !!
Normal film
Rt sided pneumothorax
Massive haemothorax pneumothorax
Flail chest Hypoxia
1- Rib fracture pain may cause the patient to hold
the chest still.
2- Pulmonary contusion (if present) causes
extravasation of fluid and blood into the alveoli.
3- Paradoxical respiration .
Pathophysiology
In the inspiratory phase, chest wall
collapses inwards forcing air out of
the bronchus of the involved lung
into the trachea and bronchus of
the uninvolved lung → mediastinal
shift to the unaffected side
In the expiratory phase, chest wall
balloons outwards so that air expelled
from bronchus of the uninvolved lung
into enters the trachea and bronchus
of the involved lung → mediastinal
shift to the affected side
This is a very insufficient form of
respiration, and the patient will die of
hypoxia and exhaustion if the condition is not
relieved.
Tension pneumothorax is MAINLY a clinical diagnosis.
Do not wait for radiographs if suspecting classic manifestations:
-chest pain.
-respiratory distress.
-cyanosis.
-refractory shock .
-decreased breath sounds.
-tympany of the affected lung.
-jugular venous distension.
-tracheal deviation to the opposite side
Tension (Massive) hemothorax is defined
as 1500 mL of blood in the chest cavity .
Patient who continues to bleed (a flow of
200 mL / h for 2-4 hours) may require
thoracotomy to control bleeding.
Failure of peripheral circulation (i.e shock) is a very common cause of trauma-related death
causes of post-traumatic shock: 1 - hypovolaemic (haemorrhagic) : the commonest= a shocked traumatized patient is considered to have a hypovolaemic shock until proved otherwise.
a traumatized patient with hypovolaemic shock is considered to have a haemorrhagic shock until proved otherwise. 2- neurogenic : severe pain . 3- cardiogenic : haemopericarcardium or cardiac trauma 4- septic : late and rare .
* assess: A. symptoms:
• thirst sensation.
• air hunger.
• coldness.
• Restlessness (in early
post-haemorrhagic state)
then weakness & fainting.
B. Signs:
• With penetrating injuries obvious blood loss.
• With multisystem blunt trauma multiple
sources of potential haemorrhage are there.
• Vital signs:
- rapid weak "thready" or absent peripheral
pulse.
- low systolic BP (↓ blood volume→ ↓ VR→ ↓
COP & ↓ ABP)
- RR: deep rapid= air hunger due to:
* hypoxia (stimulationg RC).
* acidosis. (why ??)
*↓ vagal inhibition on medullary centres
* catecholamines action on CNS.
- Temp: subnormal (↓ metabolism)
Systemic signs of shock:
• oliguria:
(< 0.5-1 ml/kg/hour) due to:
- ↓ Renal Blood Flow
- ↑ ADH release.
• skin ( of extremities):
pale (skin capillary VC).
cold (skin arteriolar VC).
clammy (sweat secretion).
cyanosis is LATE & indicates stagnant capillary circulation.
• Peripheral veins (esp neck): collapsed low CVP.
* estimate: The amount of blood loss can be estimated as follows:
- clinically (table of the next slide).
- external blood loss : (WTa –WTb x 1.5 -2)
- internal blood loss :
¤ type of injury :
haematoma in closed fracture tibia → 500 – 1500 ml.
haematoma in closed fracture femur →500 –2000 ml.
haematoma in closed fracture pelvis →2000 –3000 ml.
¤ abdominal US or CT scan .
Class I Class II Class III Class IV
Blood loss Up to 15% 15 – 30% 30 – 40% > 40%
Mental state Normal to
Anxious
Anx. to
Restless
Aggressive
or Drowsy
Drowsy to
unconscious
Pulse / min < 100 100 - 120 100 – 140 140
Systolic BP Normal Normal
(supine)
↓ ↓
Diastolic BP Normal ↑ ↓ ↓
Pulse P. Normal ↓ ↓ ↓
Cap. refill Normal > 2 sec > 2 sec > 2 sec
R.R. 14 - 20 20 - 30 30 - 35 >35
Skin Normal Pale & cold Pale
&colder
P &very cold
Urine (ml/h) 0 - 10 10 - 20 20 - 30 > 30
* treat: 1- treatment of the cause (e.g. control haemorrhage)
2- replacement of losses.
3- monitoring.
* treat: 1- treatment of the cause (e.g. control haemorrhage):
• Cannon and colleagues (1923) first observed that attempts to↑ BP in soldiers
with uncontrolled sources of haemorrhage is "counterproductive" with higher
mortality due to:
- More bleeding from the uncontrolled site.
- Cooling effect of the fluid therapy.
- Dilution of available coagulation factors by fluid therapy.
• For actively bleeding patients, any delay in interference to control haemorrhage
increases mortality, a goal of systolic BP of 80 to 90 mmHg may be adequate
with profound haemodilution avoided by early transfusion of PRBCs.
• They cannot be resuscitated until control of ongoing haemorrhage by:
1- Stopping external haemorrhage (Position, Pressure, Packing).
2- Stopping internal "intracavitary" haemorrhage.
* treat: 1- treatment of the cause (e.g. control haemorrhage).
2- replacement of losses: restore Circulating blood volume (fluid resuscitation):
1- Insert 2 wide-bore I.V. lines.:
• short, wide-bore catheters allow rapid infusion of fluids.
• Long, narrow lines (e.g. central venous catheters) have too high a
resistance to allow rapid infusion and are more appropriate for monitoring
than fluid replacement therapy.
2- Insert Foley's urinary catheter.
3- In patients with severe haemorrhage, intravascular volume restoration should
be achieved with blood or blood products (oxygen carrying capacity of
crystalloids and colloids is ZERO → if blood is lost, the ideal replacement
fluid is blood). Fresh frozen plasma (FFP) should also be transfused in patients
with massive bleeding orbleeding with ↑ PT or activated partial thromboplastin
times 1.5 times greater than control.
4- Correct metabolic acidosis:
• I.V. fluids to↑ tissue perfusion.
• If resistant (pH ˂ 7)= give NaHCO3 0.5-1 meq/kg over 5-10 min and
evaluate arterial pH to assess the need for incresing the dose.
* treat: 1- treatment of the cause
2- replacement of losses: 5- I.V. fluid administration:
IV fluids come in four different forms:
• Colloids
• Crystalloids
• Blood and blood products
• Oxygen-carrying solutions
COLLOIDS CRYSTALLOIDS
These are fluids containing solutes
in the form of large proteins or other
similarly sized molecules that are so
large that they cannot pass through
the walls of the capillaries or into the
cells.
These are fluids
containing electrolytes
(e.g., Na, K, Ca, Cl) but
lack large proteins and
molecules found in
colloids.
They can significantly ↑ the
intravascular volume because they:
- remain for long periods of time
in the BVs (large particles).
- have the ability to absorb water
from intracellular to intravsacular
compartment "can ↓ oedema".
They diffuse rapidly from
circulation.
Types of colloids:
-Synthetic:Dextran, Hetastarch
-Non-synthetic:
Human serum albumin
Plasma
Dextran: is a polysacch. solution
used for volume expansion
associated with anticoagulation (e.g.
for vascular surgery) as it interferes
with coagulation & blood typing.
Types of crystalloids:
- isotonic fluids
- hypotonic fluids
- hypertonic fluids
Tonicity Osmosis Examples
ISOTONIC
As plasma
No or minimal
- normal saline (0.9% NaCl)
- dextrose5%
- ringers lactate: (Na, K, Cl &
lactate)
HYPOTONIC < plasma - Dilute serum → ↓osmolarity→ water
moves from IV to IS compartment.
- Poor volume expanders = not used in
ttt of shock unless the deficit is free
water loss (DI) or patient is sodium
overloaded (LC).
- half normal saline
- dextrose2.5%
HYPERTONIC > plasma - derive fluid from IS to IV
- Useful for: * stabilizing BP
* ↑ UOP
* ↓ oedema.
* correcting hypotonic ↓Na
- May be hazardous in case of cellular
dehydration.
- 5% dextrose in 0.9% NaCl
(D5NS)
- 3% NaCl
- 10% dextrose in water (D10W)
• The ideal fluid to be used continues to be debated; however,
crystalloids continue to be the mainstay of fluid choice.
• Hypertonic saline as a resuscitative fluid has also immunomodulatory
action; resulting in decreased reperfusion-mediated injury with decreased
O2 radical formation.
• In patients with preexisting cardiac dysfunction, continuous
monitoring of haemodynamic (by measurement of CVP or by use of
pulmonary artery catheters).
Dynamic Fluid Response • Shock status can be determined dynamically by the cardiovascular
response (HR, BP and CVP) to rapid administration of a fluid bolus.
• Patients can be divided into 3 categories:
i. Responders: sustained improvement in cardiovascular status=
not actively losing fluid but require filling to a normal volume
status.
ii. Transient responders improve but then revert to their previous
state over the next 10–20 min= moderate ongoing fluid losses.
iii. Non-responders: severely volume depleted= likely to have
major ongoing fluid loss, usually through persistent uncontrolled
haemorrhage.
• Adults not responding to 2 - 4 L of balanced electrolyte solution as
lactated Ringer's(children are given 20 mL/kg) usually require blood
transfusions.
• Failure of response to fluid treatment may be due to:
1. Inadequate volume replacement.
2. Undetected blood loss (e.g. intracavitary).
3. Acute myocardial insufficiency (from direct injury or prolonged
coronary hypoperfusion)
3- Monitoring:
The minimum standard for monitoring of a patient in shock is:
• Continuous HR & O2 sat. monitoring (ECG & Pulse oximetry).
• Frequent non-invasive BP monitoring.
• Hourly UOP measurement.
• Systemic and organ perfusion
Most patients will need more aggressive invasive monitoring including CVP and invasive
blood pressure monitoring.
Systemic and organ perfusion
• The goal of treatment is to restore cellular and organ perfusion, therefore, monitoring of
organ perfusion should guide the management of shock (see table).
• The best measure remains hourly UOP; however, this doesn't give a minute-to-minute view
of the shock state.
• Level of consciousness is an important marker of cerebral perfusion, but brain perfusion is
maintained until the very late stages of shock and, hence, is a poor marker of adequacy of
resuscitation.
• Base deficit and lactate:
• The degree of lactic acidosis is a sensitive tool for diagnosis of shock and monitoring of
the response to ttt.
• It is measured by serum lactate level and/or base deficit from ABG analyses.
• Patients with a base deficit of over 6 mmol/l have much higher morbidity and mortality
rates than those with no metabolic acidosis.
• Base deficit and/or lactate should be measured routinely in these patients until they
have returned to normal levels.
•
• 6- Endpoints of resuscitation
• It is much easier to know when to start resuscitation than when to stop.
• Traditionally amount of fluid given should be guided by:
• Clinical improvement.
• UOP.
• CVP.
• However, these parameters are monitoring organs whose blood flow is preserved till late
stages of shock while gut and muscle beds may continue to be underperfused. Thus,
activation of inflammation and coagulation.
• This state of normal vital signs and continued underperfusion is termed occult
hypoperfusion (OH).
• Patients with OH for more than 12 hours have 2 - 3 times higher mortality rate than that of
patients with a limited duration of shock.
•endpoints (base Resuscitation algorithms are now directed at correcting global perfusion
deficit, lactate, mixed venous oxygen saturation) rather than traditional endpoints. More
research is under way to identify the pathophysiology behind this and investigate new
therapeutic options.
Base deficit and lactate:
• It is measured by serum lactate level and/or base deficit from ABG
analyses.
• Patients with a base deficit of over 6 mmol/l have much higher
morbidity and mortality rates than those with no metabolic acidosis.
Endpoints of resuscitation
• It is much easier to know when to start resuscitation than when to stop.
• Traditionally amount of fluid given should be guided by:
• Clinical improvement.
• UOP.
• CVP.
• However, these parameters are monitoring organs whose blood flow is
preserved till late stages of shock while gut and muscle beds may
continue to be underperfused. Thus, activation of inflammation and
coagulation.
• This state of normal vital signs and continued underperfusion is termed
occult hypoperfusion (OH).
• Patients with OH for more than 12 hours have 2 - 3 times higher
mortality rate than that of patients with a limited duration of shock.
• Resuscitation algorithms are now directed at correcting global perfusion
endpoints (base deficit, lactate, mixed venous oxygen saturation) rather
than traditional endpoints. More research is under way to identify the
pathophysiology behind this and investigate new therapeutic options.
* causes :
head injury, shock , hypoxia and intoxication.
* assess :
AVPU method
Alert and responsive .
Vocal stimulus elicits response.
Painful stimulus is needed to elicit a response .
Unresponsive .
Response SCORE
Eye opening response Spontaneous 4
To voice 3
To pain 2
None 1
Best verbal response Oriented 5
Confused 4
Inappropriate speech 3
Incomprehensible speech 2
None 1
Best motor response Obeys commands 6
Localizes pain 5
Withdraws to pain 4
Flexes to pain 3
Extends to pain 2
None 1
TOTAL 3 - 15
All clothes are removed using large sharp scissors.
Antihypothermic measures:
• Hypothermia in patient with bleeding leads to:
1- More bleeding 2ry to coagulopathy (due to
impaired platelet function & coagulation
cascade).
2- Hypotension.
3- Acidosis.
• Provide comfortable warm environment (avoid
excessive heat → excessive sweating→ more fluid
loss).
• Induction of controlled hypothermia in patients with
severe shock may limit the metabolic activity and energy
requirements (under trial).
Some cases may require transfer to another hospital
with higher facilities or to another department in the
same hospital. The level of care MUST not be
allowed to DROP during the transfer .
Summary of the primary survey
Airway - Airway opened, airway obstruction treated, possible definitive airway placed
Breathing - Breathing assessed, treat threats.
Circulation - Blood circulation and tissue perfusion assessed, intravascular volume loss replaced with fluids and blood, external hemorrhage controlled.
Disability - Neurologic status assessed
Exposure/environment - Patient fully undressed and environment controlled to protect from hypo or hyperthermia
Consider transfer - For higher level of care if necessary.
Adjuncts - Trauma radiographs, laboratory studies, urinary or gastric catheters, temperature monitoring, consider blood transfusion
Secondary Survey
-starts once resuscitation efforts are underwent and
preliminary X rays have been evaluated.
-steps :
* examine the patient from head to toe and from
front to back.
* complete and integrate all data (clinical,
laboratory and radiological) .
* Formulate a management plan .
Definitive Care
* after identification of the cause & region of injury (after 2ry survey).
* Patients with multiple injuries require the attention of a number of specialists.
* The most appropriate person to take the primary responsibility in such cases is
usually the general surgeon. * Patients require repeated evaluation as some injuries may present late e.g.
delayed splenic injuries, retroperitoneal duodenal injuries and subdural
hematomas.
