POLYTRAUMAMANAGEMENT STRATEGIES

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Fiaz    on Sep 09, 2009 Says :

author is indebted to all those contributors who provided pics for this presentation which is purely for academic interst for students and absolutely not for any commercia reasons
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Slide 1 : Management Strategies -Poly traumapatient DR.Fiaz Maqbool Fazili Acute Care& MAS Surgeon,Dept ofSurgery, King Fahd hospital Medinah Where we stand? Guideline for initial management of Poly trauma
Slide 2 : How much is the trauma as a problem/disease? @Statistics-of Hajj periods Trauma is a Disease- Preventive &Curative aspect_ a neglected epidemic. Large number of people ,mostly young(males) in their most productive stage of life die due to a (preventable cause)-. trauma For Hajis no age is a bar; if prompt and proper managements is instituted , many of them can be saved with an acceptable quality of life especially when our patients are guest of Allah -Hjais Theme of Lecture Towrads the Excellance In Management(Hajj)
Slide 3 : Poly trauma HOW CAN WE IMPROVISE OUR CARE? Strategy to Save lives/reduce morbidity/cost Recognise Trauma poses as a disease? Causes of trauma. Timing of Death resulting from trauma. RECOGNIZE YOUR PT) special circumstances; Error reporting -Common errors in the current trauma management—self appraisal for improvisation; voluntary [-not for punishment) Review Last year, Management strategies –(initial assessment) & Statistics. Audit THE REPORT----Recommendations
Slide 4 : Causes of Trauma_ TRANCE T-Terrorism R-Rioting & Arson A-Accidents (RTA,Falls)## N-Nuclear C-chemical E-Environmental tragedies
Slide 5 : The World Day of Remembrance for Road Traffic Victims was marked on (19th) of November, in an initiative that was begun in 2005 by the United Nations General Assembly. According to the (WHO), - not AIDS, cancer or any other disease - RTA-are the major cause of death for 15-19-year-olds worldwide., (The Lancet.) Road crashes kill 1.2 million people every year and injure or disable as many as 50 million more### young men and boys--- most AFFECTED) Men aged under 25 years are nearly three times as likely as women of that age to be killed in a RTA. 2nd leading cause of death globally among young people aged 5- 29 3rd leading cause of death among people aged 30 to 44 years.
Slide 6 : World bank report- A Problem Road fatalities continue to increase with a fatality toll between 100,000 to150,000 deaths/year May reach between 1.1 million in 2010 1.3 million in 2020. 50,000,000 injuries/year need medical attention 12% of all hospital beds occupied by trauma 350,000 permanently disabled/year $87,000,000,000
Slide 7 : Trauma Deaths Occurs….three modes# “The Trimodal Distribution” Golden hour
Slide 8 : Immediate Deaths(<1 hour) instantaneous death or within few minutes – non salvageable injury; to major organs/ structures Loss of Airway Brain Stem Laceration High C-Spine Lesion Aortic/Heart Rupture What can be done about these deaths? What role does ATLS play? GOLDEN HOUR LOST In bringing these victims to hospital
Slide 9 : CARE FLIGHT A specialist medical retrieval service performing critical care, inter hospital transport & rescue at scene.Hospital on wings/wheels Flying Docs
Slide 10 : Early Deaths (1-3 hours) Epidural/ SubduraHematoma Hemo/Pneumothorax Intra-abdominal Bleeding Pelvic Fractures #Femur/Multiple long bone Why do these patients die? M/M are preventable by timely interventions+avoidance of secondary injury due to hypoxia ;hemaorraghe;or any process to inadequate perfusion; One-fifth to one-third of all early deaths may be preventable-JAMA 1985 Standardized approaches
Slide 11 : Late (2-4 weeks) Deaths occurring in HDU ;icu and wards- Sepsis Multiple Organ System Failure How can these deaths be avoided? if our initial management has been satisfactory.
Slide 12 : KASHMIR Towards Trauma mangement Strategies
Slide 13 : Multiple Trauma –Strategical PLAN –Essential components Trauma Preparation .-Preparedness (Trauma unit,leader,etc)Symposium Triage .on scene Primary survey (ABCs) . Resuscitation . Secondary survey ( Head – to – Toe ) . Definitive Care
Slide 14 : PREPARE PROTOCOLSas per Pre-Hospital phase Hospital Management Rehabilitation & counseling
Slide 15 : Pre Hospital Phase- Scene of accident Rescue Resuscitation Relief-Rehabiltation DO NO MORE HARM Transfer rapid,safe TRIAGE ABCDE -Rapid,,Accurate on-site identification of high risk pts. If life-threat is present, CORRECT IT! If you can’t correct it: Do no more harm Oxygenate Ventilate Perfusion-iv fluids Stabilize & Transfer-Collar/hard board Rescue;Relief, Rehabilitation CONTROL OF Revealed hemorrhage . Immobilization of the patient /splinting fractures
Slide 16 : Safe transport and "packaging This slide demonstrates the immobilization and transport of an injured Modern concept of transport ideal to centers where expertise and resources are available for trauma
Slide 17 : TRANSFER-key points Transfer of the patient with multiple trauma can be hazardous. In all but the most desperate situations, the condition of the patient should be stabilized prior to transfer. Another method (Scoop and run, Resuscitate while transport ,rest at definite center) The level of monitoring must be maintained during transport, adequate resuscitation equipment & drugs should be available, hypothermia avoided The staff who accompany the patient should be experienced in transport of the critically ill. # Communicate with definitive center
Slide 18 : Towards Hospital II Towards In- hospital care Hospital phase 0-1Hour
Slide 19 : Fast fingers first-but we offer safe hands. You have to be cool Emotions You r The doctor can u save ,Her?
Slide 20 : Dont Panic? Your coomunication skills needed Here few reassuring words can soothen the atmosphere Communicatiion has been always a problem
Slide 21 : information action ER Ready with Manpower; Material;Morale; Is your ER READY? IN Hospital Preparation-TRAUMA BAY In Hospital Phase:Check list Proper air way equipment- Laryngoscope ,tubes, suction etc; should be available, visible,& Tested .checked after every reception/shift Warmed I.V – R.L . Lab – X ray /USG machine Stand by . All persons who have contact with the patient must be protected from communicable diseases . Fear of HIV, Hepatitis) . Universal precautions-Wearing gloves, masks, gowns CHECK LIST EVERY SHIFT/EVERY PT
Slide 22 : -What am I going to do first? - What’s next? You shouldnt have Dilemma?
Slide 23 : TOO MANY COOKS SPOIL THE BROTH
Slide 24 : Team leader determines priorities according to situation of pt.Assigns work. Every team member should know his job. Most efficient method of improving patient survival.; Systematic,coordinated team approach to AT ER – (after ABCDE) Coordinated Systemic Team approach Care of a Polytrauma Patient Language= A T L S
Slide 25 :
Slide 26 : Follow ATLS guidelines Detailed history/thorough physical exam is not necessary, begin The survey as follows:A B C DE Lack of definitive Diagnosis should not impede definitive treatment to save life Team work with definite roles(protocol) should be pre determined/assigned immediate Goal of ER staff on arrival of Victim? Early/PROMPT treatment of life threatening conditions -## Assessed on admission so that life threatening injuries can be corrected. The Pts condition stabilised first and plans made for further treatment of their injuries
Slide 27 : III Tasks for ER Staff- Interventions (Resuscitation+Assessment + continuous Monitoring ALL GOING SIMULTANEOUSLY. O2 mask; Iv lines; IFC Monitors (HR/Ecg;Pulse oximetry;)### Assess responses to treatment (Rule=Stabilize first and then determine DX.) Assessment Resuscitation Monitoring Never Leave PT unattended Resuscitaion & Assessment
Slide 28 : Data collection (History )while resuscitation is going on… AMPLE- A llergies,M edications,Past medical history,L ast meal or other intake,E vents leading to presentation Drug history - alter the pulse rate
Slide 29 : injury often Under estimated
Slide 30 : 2% of abd injuries(children) compression aganst spine;direct blow (handle bar;Sports;fight injury often missed
Slide 31 : Steering wheel Injury-Use (Proper) Seat Belt Seat belts certainly prevent much greater trauma can produce some trauma to the abdominal wall if improperly placed#, Major head and face injuries and major vascular injuries to the chest NO SEAT BELT
Slide 32 : NONPENETRATING WOUNDS OF HEART STEERING-WHEEL INJURY, A DECELERATIVE IMPACT FORCE MULTIPLE CONTUSIONS OF HEART WITH OBVIOUS SUBEPICARDIAL EXTRAVASTIONS OF BLOOD
Slide 33 : VARIABLE DEGREES OF SHOCK OR IN EXTREMIS DECREASED ARTERIAL AND PULSE PRESSURES OFTEN EXIST BUT NOT PATHOGNOMONIC NECK VEINS DISTENDED HEART SOUNDS DISTANT CVPRESSURE ELEVATED (PATHOGNOMONIC) CARDIAC TAMPONADE #Needs Drainage
Slide 34 : After inspection for foreign bodies . Any patient with a possible cervical spine injury should have their neck immobilised in a neutral position by collar to prevent further damage. Chin lift or jaw thrust maneuvers are recommended.-Collar apllied Great care should be taken to prevent excessive movement of the cervical spine-hyperextension /hyperflexion, or rotation.## Xray cx-Visualizing all 7 vertebrae, including the C7 to T1 interspace. ABCDE-A-airway with C-spine control
Slide 35 : Common Errors during Trauma management-self criticism serves as future guideline You assess yourself
Slide 36 : This is a clear example of a patient in whom airway management requires a so-called "surgical airway". This patient's face hit the dashboard in a motor vehicle accident. The most experienced anesthesiologist or emergency physician would have a difficult time recognizing the anatomical landmarks in intubating this patient Common ERRORS -Airway management- This is a clear example of a patient in whom airway management requires a so-called "surgical airway". The most experienced anesthesiologist or emergency physician would have a difficult time recognizing the anatomical landmarks in intubating this patient What this pt needs Dont attempt intubation
Slide 37 : Surgical Airway -Crico- thyroidotomy ,; only way to attain an adequate airway in this patient was with a surgical cricothyroidotomy
Slide 38 : Do not,….put NGT Patient who has evidence of a Basilar skull fracture with , “Raccoon eyes" sign. Place NGT through the mouth . Passing NG tube through the nose. can go through injured cribiform plate, and pass into the brain.
Slide 39 : B-Breathing Expose the patient's chest, quickly to assess rapidly; Auscultation to assess adequacy of air exchange# Percussion may reveal the presence of air or blood in the chest, ##Recognise & treat life-threatening conditions Tension pneumothorax Open pneumothorax Flail chest Hemothorax; Cardiac tamponade. #
Slide 40 : C- CIRCULATION Hypovolaemia due to Hemorrhage is the predominant cause of post injury deaths . Notice the indirect informants of circulation status within seconds Level of consciousness Skin color Pulse –rate,character,volume. Capillary refilling BP BP-unreliable Tachycardia is the predominant sign of blood loss
Slide 41 : Hypovolaemic shock commonest All Types of SHOCK may be present. The presence of a "normal" blood pressure does not exclude significant intra-abdominal bleeding,## Injury to hollow viscera especially with short prehospital times, Young athletic victims. SHOCK in Trauma
Slide 42 : ` Assessment of blood loss
Slide 43 : Fluid resuscitation in Trauma- What , How < Where; (Which size ) Insert Two large-bore short (14) IV's peripherally, Give One liter of balanced salt solution, either Ringer's Lactate or normal saline,(warm) during the first few minutes resuscitation of the major trauma victim. Based on 3:1 rule when using crystalloids DO NOT OVER INFUSE?
Slide 44 : Observe Response Shock therapy(fluid challenge ) A sustained improvement in the signs of shock will hopefully be seen, and this suggests blood loss is less than 25% of the blood volume. If the improvement is short lived, this indicates continuing haemorrhage that requires control. Surgical intervention may be required and further blood transfusion necessary. If no improvement in the condition of the patient is seen Blood loss is greater than 40% Almost certainly from thoraco-abdominal or pelvic injury. It is in these patients that O negative blood should be considered.
Slide 45 : Q.How we Evaluate our resuscitation? Urine output- Sensitive index Adult- 50ml/hour(0.5ml/hr) Child- 1ml/kg hour <1year -2ml/kg/hour
Slide 46 : All trauma victims who are shocked are hypovolaemic (blood loss) until proven otherwise. If inadequate response to shock therapy- No external source of bleeding, Consider Hypovolemia resulting from :bleeding in hidden spaces; Intra- abdominal, Retroperitoneal, Intra thoracic area,-cnfrm by need FAST/CT/DPL PELVIC Fracture /femur # Penetrating injuries with arterial or nerves involvement Commence rapid Warm intravenous infusion blood immediately. Which shouldn’t take much time#####
Slide 47 : Type of blood Time required for preparation Full crossmatch 30-40 minutes ABO Compatible 10 minutes Uncrossmatched ORhesus Negative Available Immediately
Slide 48 : Errors due to Over-resuscitation with fluids Over-resuscitation is a consequence of aggressive fluid management in the face of hypotension.—compartment syndrome;;consider permissive hypotension The pulmonary consequences of over-resuscitation are fatal in polytrauma pts.### A new protocol was instituted in 2003 ,clear guidelines to limiting fluids, beginning inotropic agents, & rapid control of bleeding.
Slide 49 : D- DISABILITY ( NEUROLOGICAL EVALUATION ) Establish the patient’s level of consciousness & pupillary sign & reaction . Simple way to detect the level of consciousness is the (AVPU) method : A - Alert V - Responds to vocal stimuli P - Responds to painful stimuli U - Unresponsive The Glasgow Coma Scale is more detailed neurological evaluation that is quick and simple Head injury ; Decreased Oxygenation; Shock . GCS +7 is serious
Slide 50 : E - EXPOSURE The patient should be completely undressed with precautions –preservations (esp;female pt) . Cover the patient to prevent HYPOTHERMIA/ * Warm- blankets; * I.V Fluid; * Warm environment For Privacy..
Slide 51 : Seat Belt Sign www.emedicine.com Seat belt sign signifies serious injury inside;## The introduction of seatbelts reduced mortality following severe motor vehicle accidents from about 5.6% to 3.4%.
Slide 52 : Delayed presentation; seat belt sign/ ecchymosed can clue. surgical pain; late abd signs-small bowel;duodenum;colon –all can b injured Missed seat belt injury Delayed presenation
Slide 53 : Spinal injury? - use Log rolling### The cervical and thoracolumbar regions are most commonly affected by trauma, and appropriate radiographs should be taken. The patient must be log rolled (figure 8) and the entire spine examined for deformities or injuries.## The rest of the back should also be examined at this point to exclude other injuries.
Slide 54 : Don’t forget the back Turn the casualty over when you can do so safely LOOK for injuries- Palpate ribs, spine, sacrum for tenderness and irregularities ## Dress the wound with an occlusive dressing
Slide 55 : Rupture urethra signs- Scrotal Hematoma The other three signs are Perineal hematoma Scrotal hematoma, Blood at the urethral meatus. # the abnormal position or absence of a prostate, or a "high-riding prostate" is one of the three major clinical signs; Possible membranous urethral disruption in the male with blunt pelvic trauma. DO NOT ATTEMPT CATHETER
Slide 56 : Grey Turner Sign-don’t underestimate it - Flank ecchymosis from internal bleeding
Slide 57 : Evisceration Injuries - GO TO OR Extrusion of abdominal contents secondary to penetrating abdominal trauma Entrance Wound
Slide 58 : Ancillary aids-Lab & xrays BLOOD: CBC, CHEM: KFT/LFT AMYLASE. ABG *for Grouping, Drug level, etc) URINE exam.(preg test) Initial Hb/Hct may be misleading due to hemoconcentration or hemodilution, so repeat Hb/hct is recommended Pregnancy test –blood Xrays- Cx;Chest;Pelvis# FAST:DPL CT SCAN free air under the diaphragm,-OR
Slide 59 : RE-ASSESSMENT DOCUMENTATION The patient should be repeatedly reassessed, particularly if clinical signs change. Any immediately life threatening condition diagnosed should be rectified without delay. Penetrating wounds and impalements must be left for formal surgical exploration. Any external bleeding should be stopped by using direct pressure
Slide 60 : The further treatment of the patient will depend on the injuries detected during the preceding examination. The highest priority is given to those that are potentially life threatening. Special Protocols FOR Hajis
Slide 61 : Errors due to Inappropriate management (decisions ) or lack of protocols on unstable/Haji patients . Unduly long initial op procedures done on unstable pts=(7.8%) Damage control surgery principles not followed Inappropriate interhospital transfer of unstable pts=3.1% Unstable pt sent to Ct scan=3.1%? @ Policy of Permissive Hypotension not instituted ## management Policy for solid organ injuries for Hajjis . The principles of damage control surgery are: Control hemorrhage Prevention contamination Avoid further injury
Slide 62 : Lethal triad –”prevention is the KEY Most of POLY Trauma Deaths due to
Slide 63 : Prevention is better than cure Follow safety standards Dont cross Red light use seat belts Passenger -Driver Education: Speed checks Driving too fast Tougher Police enforcement for violators inexperience of complex traffic conditions STOP Road rage Exhausted Drivers-Haj season
Slide 64 : The Editorial concludes: "But the individual solution lies with what is perhaps one of the hardest things to change - Human Behaviour. Road accidents disproportionately affect young people. Being taught about road safety from a very young age must become a priority, with adults setting a good example at all times." The Lancet
Slide 65 : COULD WE HAVE DONE BETTER Q;How to improvise? Ans ;SELF AUDITING/CRITICISM is necessary # How many ERRORS occurred in our ER set up during …….. Management ? 1-Airway management 2.Hemorrhage control 3-Inappropriate Mx of unstable patients 4-Complications of procedures 5-Inadequate prophylaxis 6-Missed or delayed diagnoses 7-Over-resuscitation with fluids; 8-Transfer errors-Other poor coordination decisions
Slide 66 : In All cases it is essential to ensure that those treating the patient are safe to carry out the work. DO NO MORE HARM
Slide 67 : Flying Doctors Dont exhsust your force before actual combat Thank u THANKS FOR YOUR ATTENTION Dr. Fiaz Maqbool Fazili

 


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POLYTRAUMA_MANAGEMENT STRATEGIES





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