Triage in Polytauma

Prof. Dr. A. Chandrasekaran M.S., Ph.D.,Department of Orthopaedic surgery,

Sri Ramachandra University,Chennai. 600116.

Objectives

• To know correct sequence of triage

• To know primary, secondary and tertiary survey

• To know history of trauma incident and thus assume the type of injury

• To set Guidelines for initial resuscitation and definitive treatment

Road traffic accident

Speed thrills

Less frequent

Triage at the site

Arrival in Hospital

Triage in Emergency

Triage in Emergency

Triage in Emergency

Triage in Emergency

Definitive treatment

Post operative ICU

Polytrauma Multisystem trauma

• Injury = the result of harmful event that arieses from the release of specific forms of energy.

• “polytrauma” = Multisystem trauma = injury of two or more systems, one or the combination imperil vital signs.

Polytrauma Injuries

• Brain injury • Amputation• Fractures-Open• Soft Tissue Injury-Open• Psychological• Infectious Complications• Neurologic

– Spasticity– Seizures– Hydrocephalus

• Medical Complexity– Cardiovascular– Nutritional requirements– Infectious complications

• Auditory/vestibular• Vision Loss Complex Pain • Musculoskeletal

– Orthopedic Trauma– Peripheral Nerve Injury– Heterotrophic Ossification– Contractures

• Wounds

Specialty and Consult Services

• Psychiatry• Physiatry• Internal Medicine• Neurology• Infectious Disease• Pulmonary• Gastroenterology• Endocrinology• Cardiology• Enterostomal Nursing

• Neurosurgery• Orthopedics• Plastic Surgery• Ophthalmology• Neuro-opthamology• Urology• ENT• Audiology• Dental• Podiatry• General Surgery

Care of trauma patient

• Pre hospital care

• Emergency department care

Trauma deaths

First peak • Within minutes of injury • Due to major neurological or vascular injury • Medical treatment can rarely improve outcome Second peak • Occurs during the 'golden hour' • Due to intracranial haematoma, major thoracic or

abdominal injury • Primary focus of intervention for the Advanced

Trauma Life Support (ATLS) methodology Third peak • Occurs after days or weeks • Due to sepsis and multiple organ failure

Trauma care

• Critical care specialists play a vital role in stabilization and diagnostic phases of trauma care.

“what happens in this period often determines the outcomes of care”

Ethical dilemma

   Allowing a terminally sinking patient to die may appear unethical, but neglecting some patients having a greater chance of survival resulting in avoidable deaths is more unethical.

Documentation

“If it was not documented,

it was not done”

NO ABBREVATIONSNO ABBREVATIONS

WNL

““Within Normal Limits”Within Normal Limits”

OrOr

““We Never Looked”We Never Looked”

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Triage

• Triage come from the French word “”Trier”

which means to sort.

• We use triage in the emergency

department to identify those patients that

need care first

Multiple casualties

• several casualties at the same time.

1. Alarm ER services2. Assess the scene - without putting

your safety at risk.3. Triage

'do the most for the most'

1. Make the area safe

• protect yourself, the casualty and other road users.– Park your car safely, turn lights on, set hazard lights

flashing.– Do not across a busy motorway to reach other side– Set others to warn other coming drivers– Set up warning triangles or lights 200 metres in each

direction.

– Switch off ignition of any damaged vehicle.

• Is anyone smoking?

2. Check all casualties

• quick assess• no moving • apply life-saving treatment

3. Treat

• in the position found• first life-threatening or potentially

serious injuries

4. Search all area

What is Trauma Triage?

Patient NeedsPatient Needs Hospital Hospital ResourcesResources

Trauma patients are assessed and Trauma patients are assessed and transported to the most appropriate transported to the most appropriate hospital for that patient’s injuries.hospital for that patient’s injuries.

Trauma System GoalTrauma System Goal

• To get the right patient To get the right patient

• to the right hospital to the right hospital

• at the right time.at the right time.

Mechanism of injury

• Blunt injury

• Penetrating injury

Stimuli that initiate the physiologic response to trauma

• Perception of pain

• Shock

• Blood loss

• Hypoxia

• Acidosis

• Hypothermia

Mediators of physiologic response to trauma

• Sympatho-adrenal axis• Hypothalamic-pituitary adrenal axis• Anti-diuretic Hormone• Renin and Angiotensin• Endogenous opioids• Locally produced • Trauma, results in alteration of nearly all

physiologic systems

Physiologic Reponses

• · Psychologic response• · Altered Vital Signs• · Edema• · Impaired Oxygen Transport• · Hypermetabolism• · Altered Protein Metabolism• · Altered Glucose Metabolism• · Altered Coagulation & Inflammation• · Leucocytosis• · Altered Immunity

ATLS Scheme

• The ATLS® scheme has four components:

• Primary Survey

• Resuscitation

• Secondary Survey

• Definitive Care

• It is important to try and achieve as much of this as possible simultaneously.

Revised Trauma Score (RTS)

• RTS has been shown to be a more reliable predictor of outcome

• RTS is based on three physiologic measures

· Glasgow coma scale score

· Respiratory rate

· Systemic BP

• RTS remains in common use today

Assessment of the injured patient

• Primary survey and resuscitation – A = Airway and cervical spine – B = Breathing – C = Circulation and haemorrhage control – D = Dysfunction of the central nervous system – E = Exposure

• Secondary survey

• Definitive treatment

Primary Survey

• Find and correct life threats• Most obvious or dramatic injury usually is

not what is killing the patient!• If life-threat is present, correct it!• If it can’t be corrected- Support oxygenation, ventilation, perfusion- Transport!!

Airway and cervical spine

• Always assume that patient has cervical spine injury

• If patient can talk then he is able to maintain own airway

• If airway compromised initially attempt a chin lift and clear airway of foreign bodies

• Intubate or cricothyroidotomy • Give 100% Oxygen

Airway

Breathing

• Check position of trachea, respiratory rate and air entry

• If clinical evidence of tension pneumothorax will need immediate relief

• Place venous cannula through second intercostal space in the mid-clavicular line

• If open chest wound seal with occlusive dressing

Circulation and haemorrhage control

• Assess pulse, capillary return and state of neck veins

• Identify exsanguinating haemorrhage and apply direct pressure

• Place two large calibre intravenous cannulas Give intravenous fluids (crystalloid or colloid)

• Attach patient to ECG monitor

Dysfunction

Assess level of consciousness using AVPU method A = alert V = responding to voice P = responding to pain U = unresponsive

Assess pupil size, equality and responsiveness

Exposure

• Avoid hypothermia

Fully undress patients

Avoid hypothermia

Primary Resuscitation

• · Immobilize C-spine (manual & rigid collar)• · Keep airway open• · Oxygenate• · Rapidly extricate to long board (SMR)• · Begin assisted ventilation with BVM• · Expose & Protect from exposure• · Apply and consider inflation of PASG• · Consider intubation• · Transport• · Establish IVs enroute• · Reassess and early notification enroute

Triage categories

Triage categories Cat Definition Colour Treatment Example

P1 Life-threatening

Red Immediate Tension pneumothorax

P2 Urgent Yellow Urgent Fractured femur P3 Minor Green Delayed Sprained ankle P4 Dead White

Triage

• Ability to walk • Airway • Respiratory rate • Pulse rate or capillary

return

MCI management Principle

Less than 30 seconds

per patient

Secondary Survey

• “The secondary survey does not begin until the primary survey (ABC) is completed, resuscitation is initiated

• and the patients ABCs are reassessed”• “Secondary survey is a complete head-to-

toe evaluation along with vital signs”• “A more detailed survey is required in the

unresponsive patient”

Secondary Survey

• ‘Tubes and fingers in every orifice’

Summary

• Do the best for the most

• Correct life threatening injury

• Sort and tag the patient

• Move to the treatment area

• Then to the loading area

• Practice the art, be prepared

Triage in the EmergencyDepartment

• The patients that to the emergency department have varying degrees of acuity. – Very sick- life threatening illness or injury – Moderately sick – Minor illness or injury that is not life-threatening.• Rapid assessment and resuscitation of patients with severe trauma or shock increases survival• Patient’s who are less sick will not deteriorate significantly over time

Triage- An important position

• When a patient arrives in the Emergency

Department he/she must be quickly

assessed and examined to determine

appropriate triage category

• Typically performed by a very experienced

nurse

Pediatric concern

• Apneic children may have a treatable breathing problem

• Provide 5 rescue breaths for non breathing children

• Obeying commands may not be the appropriate gauge of mental status of the children

Investigations

• X rays:• Chest• Abdomen• Pelvis• Cervical spine• Long bones• Skull, etc.• “They should be taken urgently, but should

not delay patient resuscitation”

Triage - Conclusion

• Reduces stress and enables responders to focus

• Responders become more efficient to do the greatest good

• Improves outcomes by identifying immediate needs

• Prioritizes limited resources