DR A.R.BAKA DEPARTMENT OF SURGERY FEDERAL MEDICAL CENTER, YOLA

PRESENTATIONy INTRODUCTION y PRIMARY SURVEY y SECONDARY SURVEY y IMMEDIATE MANAGEMENT OF MUSCULOSKELETAL INJURIES y INTENSIVE CARE AND SCHEDULED DEFINITIVE SURGERY y CONCLUSION

INTRODUCTIONy Trauma represents the major killing factor in young patients 17) with consecutive systemic trauma reactions which may lead to dysfunction or failure of remote primarily not injured- organs and vital systems.

INTRODUCTION CONT.Or it refers to trauma in which the patient suffers two or more major injuries which may cause physiological instability. The term was coined in military medicine, where it is often due to gunshot or explosive injuries. The polytrauma team consist of many specialities including orthorpaedic surg., emergency physicians,trauma surgeons, neurosurgeons, and other surg. subspecialities

INTRODUCTION CONT.Each member of the team should be familiar with the basics of trauma resuscitation.

INITIAL ASSESSMENT AND MANAGEMENTy y y y

Primary objective is survival Timing and priorities(Triage sorting of casualities by priority of Tx) Follow defined established algorithms Establish time dependent management phases for trauma patient in the first 24hrs which comprise:y

Primary survey with base line diagnostics and immediate life-saving procedures and establishing

INITIAL ASSESSMENT AND MANAGEMENTAccess to life-support systems according to the A-B-C algorithm of ATLS protocol - damage control surgery in patients who are not responsive to the initial measures of resuscitation: surgical control for exsanguinating hge and decompression of body cavities(life saving surgeries) - Secondary survey in hemodynamically stable patients with elaborate diagnostics including a head to toe examination and further radiologic work-up(CT scan, conventional x-rays,angiography,etc)

INITIAL ASSESSMENT AND MANAGEMENTy Delayed primary survey; decontamination,surgical exploration and Mx of non-immediately lifethreatening injuries,temporary fracture fixation

PRIMARY SURVEYy During the primary survey, the injured patient is rapidly assessed according to the algorithm of the ATLS protocol and life preserving therapy is instituted simultaneously y The Tx priorities are based on the likelihood of a pat to die within a short time from a life-threatening injury, according to the A-B-C-D-E mnemonic y The 1* survey must be repeated anytime a patient s status changes

PRIMARY SURVEY CONT.y Airway (with cervical spine protection) y An obstructed airway is one of the most immediate and deadliest threat to life y Goals to provide a patent airway y Maintain in-line cervical stabilisation y Protect airway from future obstruction by blood,edema,vomitus,other possible causes of blockade y Anticipate potential problems y Check gag reflex(ability to protect airway)

PRIMARY SURVEY CONT.y Airway Mx y Jaw-thrust maneuver may be necessary(base of tongue usually obstructs) y Chin-lift manuever(dangerous in trauma pat may exacerbate c spine injury) y Remove foreign bodies seen y Suction to remove secretions and blood y Orapharyngeal airway in unconscious pat y Nasopharyngeal in partially conscious pat y Laryngeal mask airway as a rescue airway

PRIMARY SURVEY CONT.y Definitive airway Mx y Achieves airway patency,protects the lungs from aspiration, allows for positive preesure ventilation y OROTRACHEAL INTUBATION is the criterion standard for airway Mx an endotracheal tube y NASOTRACHEAL INTUBATION for spontaneously breathing pat. C/I in facial fractures,basilar fractures y SURGICAL AIRWAY is a last resort. When orotracheal has failed,obstruction of trachea by blood/edema is complete,totally transected airwayy

Cricothyroidotomy

PRIMARY SURVEY CONT.y Adjuncts to orotracheal intubation y Fibreoptic intubation y Retrograde intubation y Light wand

PRIMARY SURVEY CONT.y Cervical spine protection y In-line stabilization maintained for pat with suspected or confirmed c-spine fracture y Mechanism of injury considered to predict danger to c-spine y Hx of ability to walk or move all 4 limbs following an injury does not rule out the possibility of unstable c-spine fracture y Pat with facial injury,significant blunt trauma,neurologic deficit must be assumed c-spine injury until proven otherwise y Protection provided by holding the head in neutral position facing forward. It ca be secured with a hard cervical collar. y When intubating, in c-spine injury,maintain neutral position. y Exclude spinal cord injury clinically or radiologically

PRIMARY SURVEY CONT.y BREATHING y Any immediate life threatening obstacles to breathing, namely tension pneumothorax,open pneumothorax,flail chest ,or massive hemothorax must be diagnosed and Tx quickly y Watch pat breath y Listen to the lungs y Bilatral chest expansion y Look for cyanosis

PRIMARY SURVEY CONT.y Monitor pulse oximetry- can be unreliable in peripheral poor perfusion y Arterial blood gases maybe indicated y TX y O2 at 6-10L/min via nonrebreathing face mask to all polytrauma pat y Ventilate pat y Tx open pneumothorax,tension pneumothorax,flail chest,massive hemothorax

PRIMARY SURVEY CONT.y OPEN PNEUMOTHORAX(sucking chest wound) y Chest wound with diameter >2/3rds of trachea can become sucking y Air moves preferentially through the wound and ipsilateral lung deflates y Tx bandage taped on both sides so air can escape but cannot be sucked into the chest y Follow by tube thoracostomy

PRIMARY SURVEY CONT.y TENSION PNEUMOTHORAX y Deadly condition y Allows air into into interpleural space but does not escape y Lung collapse y Mediastinum pushed into opposite hemithorax y A clinical diagnosis:

Chest pain Respiratory distress Shock refractory to fluids and pressors Decreased breath sounds and tympany of the affected lung Jugular venous distention Cyanosis Tracheal deviation to opposite side

PRIMARY SURVEY CONT.y Suspect tension pneumothorax in pat who is hypoxic or in shock, esp if crepitus,evidence of trauma to ipsilateral chest wall y Tx 16-gauge needle inserted into the 2nd intercostal space in the midclavicular line y Quikly followed by chest insertion into the 5th ICS in the midclavicular line to reexpand the lung

PRIMARY SURVEY CONT.y FLAIL CHEST y 3 or more consecutive ribs fractured at 2 sites y May result in significant morbidity and mortality y Causes hypoventilation y Paradoxical breathing may be observed y Maintain a high index of suspicion in any thoracic injury y Begin Tx immediately y Confirm diagnosis as soon as possible with CXR

PRIMARY SURVEY CONTy Tx

maximize oxygenation of lungs using PPVopiates , nerve block,

y Effective pain control y Judicious fluid mx

PRIMARY SURVEY CONT.y MASSIVE HEMOTHORAX y Can cause problem with breathing and circulation y 1500ml of blood in the chest cavity y Caused by disruption of a systemic or hilar vessel y Chest can accommodate the entire circulating volume of blood y Hemorrhagic shock maybe severe

PRIMARY SURVEY CONT.y CIRCULATION AND HEMORRHAGE CONTROL y Markers for adequate circulation:

Level of consciousness Skin temperature and color Nail bed capillary refill time Rate and quality of the pulses

y Control external bleeding with pressure y Log roll of pat to identify posterior bleeding y Cardiac and BP monitoring y Draw blood for laboratory studies,Hct(pcv),PT

PRIMARY SURVEY CONT.y Resuscitate with 2 large bore(14-16-gauge)IV catheters using warm fluids and packed RBCs y Control hemorrhage y Tx cardiac tamponade,cardiac arrest,massive hemothorax y Consider resuscitative thoracotomy y Nurse pregnant pat in Lt recumbent position

PRIMARY SURVEY CONT.y Fluid and blood resuscitation y Hemorrhage control y FAST y DPL y Tibia fracture ~750mls, femur fracture~ 1500mls of blood loss y Pelvic fracture ~ several liters, may require laparatomy ,CT,angiography. Use of skeletal traction in hemipelvic displacement

PRIMARY SURVEY CONT.y Cardiac tamponade y Hemopericardium prevents diastolic filling of the heart and HF y Classic signs are Beck s triad:

Hypotension Venous distension Muffled heart sounds

y y y y y

Kussmaul sign-increased jugular venous pulsation on inspiration Pulsus paradoxus Cx-ray-globular heart Unstable pat requires urgent thoracotomy In stable pat diagnosis byy y

Echocardiography Pericardiocentesis

y Subxiphoid pericardiotomy is both diagnostic and therapeutic

PRIMARY SURVEY CONT.y Cardiac arrest y Any pat without pulse should be assessed with defibrillator paddles or cardiac monitor y Tx unstable arrhythmias with electrical cardioversion y Resuscitative thoracotomy y Loss of vital signs in penetrating chest injuries y Tx cardiac tamponade y Gain direct control of intrathoracic hemorrhaging vessel y Perform open cardiac massage/defibrillation y Cross-clamp the aorta to slow blood loss distally and increase perfusion to the heart and brain promimally

PRIMARY SURVEY CONT.y DISABILITY y Perform a quick neurologic exam y Level of consciousness y Pupillary size and reaction y Gross motor functioning y GCS y Altered level of conscousness maybe due to:

Intoxication Hypoxia Hypotension Cerebral injury Hypothermia/hyperthermia hypoglycemia

PRIMARY SURVEY CONT.y EXPOSURE/ENVIRONMENTAL CONTROL y Expose pat by removing clothes y Control hypothermia

SECONDARY SURVEYy The secondary survey san only begin after the resuscitative measuers of the primary survey are completed according to the A_B_C_D_E algorithm and pat has been hemodynamically stabilized and demonstrate normal vital functions. y The sec sur is a head-to-toe examination designed to identify any injuries that might have been missed. y Constant reevaluation to identify trends in physical examination and laboratory findings.

PRIMARY SURVEY CONT.y Tx evacuation of blood with a large bore (36-40F) chest tube y Possible autotransfusion y intravascular volume replaced IV with fluids and blood y Thoracotomy maybe required to control bleeding vessel

SECONDARY SURVEY CONT.y FOCUSED PATIENT HISTORY y Sec exam focused on the trauma and pertinent information y Sx pain,shortness of breath,other sxs y Allergies to medication y Medication taken y Past med/surg Hx y Last meal-risk of aspiration y Eventa leading up to trauma

SECONDARY SURVEY CONT.y HEAD AND SKULL EXAMINATION y Head trauma causes 50% of all trauma deaths y Should be highest priority during sec surv y Intracranial bleeding be identified by neurologic exam and noncontrast CT y Suspect in

Focal neurologic signs Altered mental status Loss of consciousness Persistent nausea and vomitigor headache

SECONDARY SURVEY CONT.y GCS y Eyes for acuity, pupillary size,extraocular movts y Fundoscopy for preretinal hges y Skull eamined for lacerations,fracture,tenderness y Signs of basilar fracture-Battle sign(bruising at the mastoid area, raccoon eyes(oeriorbital ecchymoses),CSF rhinorrhoea,otorrhea

SECONDARY SURVEY CONT.y MAXILLOFACIAL EXAMINATION y Look inside the mouth,nose for bleeding/haematoma y Le Fort fractures y Consider early intubation to protect the airway

SECONDARY SURVEY CONT.y NECK EXAMINATION y Trachea,pharynx/esophagus,great vessels y Consider early intubation y Consult ENT or general trauma surgeon

SECONDARY SURVEY CONT.y CHEST EXAMINATION y Thoracic injury accounts for 25% of the trauma related mortality rate. y Inspect the chest for bruising,deformity,and motion of the chest wall during respiration y Auscultate the heart for muffled heart sounds/murmurs y Auscultate the lungs for breath sounds y Palpate the chest forsubcutaneous emphysema

SECONDARY SURVEY CONT.y Injuries tha must be considered in the secondary examination y Traumatic rupture of the aortaCXR(widened mediastinum),aortography,CT angiography. Tx repair/interpositional graft

Traceobronchial disruption- chest does not expand after chestb tube insertion. Tx bronchoscopy/repair Diaphragmatic rupture-CXR-bowel in thorax. Tx insert NG tube to decompress stomach/surgery Blunt cardiac injury-ECG,US. Tx-consult cardiothoracic specialist

SECONDARY SURVEY CONT.y Pulmonary contusion-CXR opacities. Tx-fluid restriction,oxygen,analgesia y Simple pneumothorax-can develop into tension pneumothorax,esp if intubation and PPV are used. Txchestb tube y Hemothorax may become massive hemothorax, may clotand cause long entrapment or become an empyema. Tx-chest tube y Mediastinal traversing wounds-this may damage the heart,great vessels,tracheobronchial tree,esophagus. Tx-operating room/bronchoscopy,endoscopy

SECONDARY SURVEY CONT.y ABDOMINAL EXAMINATION y Blunt/penetrating trauma y FAST/DPL y CT scanning

SECONDARY SURVEY CONT.y SPINAL CORD/CERTEBRAL COLUMN y Palpate every spinous process for point tenderness y Spinal radiography to evaluate damage y Hypotension and slow pulse should be assessed for neurologenic shock and a high spinal cord injury y Complete neurologic examination

SECONDARY SURVEY CONT.y Cervical spine clearance y No focal neurological deficits y No distracting injuries,eg,gunshot wound,pelvic fracture,long bone fracture y No intoxications,eg,alcohol,opiates y Full orientation and awareness y No midline tenderness y Perform c-spine radiograph

SECONDARY SURVEY CONT.y Genitourinary examination y Perform a rectal exam y Examine the perineum y Check for urethral/meatal blood

IMMEDIATE MANAGEMENT OF MSS INJURIESy Palpate all joints and long bones y Assess pulses,capillary refill y Sensation y Motor strenght y Determine limb lenghts indicates y Hip fracture y Dislocation y Pelvic fracture

SECONDARY SURVEYy Splint all fracture above and below joint after realignment of the limb y Perform immediate reduction of dislocationsneurovascular compromise

SECONDARY SURVEYy Pelvic fractures, suspect y Appropriate mechanism of injury-high energy trauma y Pain in pelvic region y Leg length discrepancies y Destot sign(hematoma of scrotum or ing lig) y Earle sign(hematoma or tenderness along bones on DRE) y Roux sign(asymmetry in the distances b/w the greater tronchanter and pubic spine on each side)

SECONDARY SURVEYy Pelvic fracture cont. y Test for pelvic stability y Order AP pelvic XR y DRE-maybe the only indication of a dangerous open pelvic fracture impinging on the rectum y Can cause damage to nerves,genitourinary sructures,rectum y Presentation of PFshock,hypotension,bladder/urrthral injuries y Tx stabilization with pelvic binders/sheet,external fixation

SECONDARY SURVER CONTy Open fractures: All open fractures are Tx initially with y Immobilization y Irrigation of wound y Debridement of devitalized tissue y Prophylactic antibiotics y Definitive debridement and stabilization-proceed to the operating room

SECONDARY SURVEY CONT.y Soft tissue and joint injuries y Crush syndrome y Gunshot wounds y Geriatic polytrauma y Polytrauma in children y Polytrauma in pregnant patients

INTENSIVE CARE AND DEFINITIVE SURGERYy ICU transfer is aimed at further stabilization of polytrauma patient and for restoration of the following end points of resuscitation y Stable hemodynamics without need for vasoactive/inotropic stimulation y No hypoxemia,no hypocapnia y Serum lactate 2mmol/l y Normal coagulation y Normthermia y Urinary output>ml/kg/h

INTENSIVE CARE AND DEFINITIVE SURGERYy The pathophysiological phase of hyperinflammation b/w days 2-

4 after trauma is a time period of enhanced susceptibility to a second-hit injury and thus does not allow surgical intervention y Physiological window of opportunity b/w days 5-10 after trauma. Fully resuscitated pat is a candidate for changes in operative strategies and definitive scheduled surgical procedures,eg, change from external to internal fixation of long bones and pelvic ring #s,skin grafting,etc y 2nd week preiod after trauma-phase of immunosuppression- no surgery should be performed due to the susceptibility of a second-hit y Only after the 3rd week should further reconstructive operation be performed, if required,eg, secondary cancellous bone graft,definitive orthorpaedic reconstructive interventions

CONCLUSIONy The complex Mx of polytraumatized patients can be

optimised by standardized and validated approaches using well-established algorithms, such as the ATLS program y New concepts in recent years have demonstrated highly critical polytrauma pat in extremis have a significantly improved overall outcome due use of damage control surgery y The kinetics of the physiological response to severe injury must be taken into account for the timing and priorities of surgical interventions in the further course after trauma

CONCLUSION CONT.y This golde balance b/w mandatory primary and secondary measures and the knowledge of the pathophysiological reactions inadherence with established diagnostic and therapeutic algorithms will help improve the overall outcome of polytrauma patients.

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