Approach for poly-trauma patient

Report
Dr. Hany Victor
Lecturer of Anesthesia and ICU
ETC Instructor
Objectives
 Case presentation on poly-trauma patient.
 Discussion on the case
 Approach to poly-trauma patient
 Recommendation
 MCQ
Case
 Male patient 28 years presented to the ER following a
motor car accident 30 min ago complaining of chest
pain, cut wound in the forehead with minimal
bleeding and pain in the right forearm.
 By history the patient had a blunt trauma to the head
and chest in the dashboard. Other previous medical
history is irrelevant.
On examination
Airway: Clear
 Cervical Spine immobilization after neck examination
with no major abnormality
Breathing:
 RR: 20/min
 Equal air entry bilateral with no adventitious sounds.
 Tenderness over the sternum.
 SpO2: 95% on room air.
Circulation:
There is no major site of bleeding, vital signs include:
 HR: 100/min felt central and peripheral, equal on both
sides.
 Blood pressure: 100/60 mmHg.
 Capillary refill time: 1.5 sec.
 Temp: 37.1C
 Neck veins not congested
 There is wound in the forehead 5X3 cm.
Disability
 GCS 15/15
 No loss of cons, no nausea or vomiting, no bleeding per
orifices, no transient amnesia and no fits.
 Pupils are equal bilateral and reactive to light.
 Blood sugar 140 mg/dl.
Exposure
 No major bleeding
 No major deformity
Discussion on part one
of the lecture
Types of assessment
1. Primary Survey and resuscitation
• Identification of Life threatening conditions
• AcBCDE Approach
2. Secondary Survey
•
•
•
•
Detailed head to toe examination
Medical history
All lab and radiology investigation ordered
Management Plan
8
PURPOSE OF THE INITIAL ASSESSMENT
Identification of LIFE-THREATENING
emergencies
Assess – Change - Reassess
Initiation of LIFE-SAVING
measures (CPR)
Illinois EMSC
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5 second Round
•Pt is conscious or not
•Airway
•Ventilation
•Signs of massive external hemorrhage
•There is any deformity
•Skin color and temp with feeling pulse
Illinois EMSC
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Primary Survey
Airway/
Cervical Spine Control
Breathing
Circulation
Disability (neurological)
Expose
Illinois EMSC
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Assessing Airway
Is the airway:
 Clear and safe?
 At risk?
 Obstructed?
AIRWAY INTERVENTIONS
Jaw thrust Vs Head tilt.
Deliver Oxygen (mask with
reservoir).
Use Rigid suction.
Secure airway.
Illinois EMSC
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5 Chest clues in the neck
 Wounds
 Distended neck
veins
 Tracheal position
 Surgical
emphysema
 Laryngeal crepitus
CERVICAL SPINE STABILIZATION
Place hands on either side of
the head cervical collar.flv
Maintain neck midline
“manual in line stabilization”
Illinois EMSC
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Breathing and ventilation
Aims
 Support if
inadequate
 Eliminate any
immediately life
threatening
thoracic condition
…..
Breathing and ventilation
Inspection
 Respiratory rate
 Effort of breathing
 Symmetry
 Wounds & marks
Palpation
Tender points, equal
expansion
Percussion
No abnormal note
Auscultation
 All lung zones
BREATHING INTERVENTIONS
If breathing is absent, start
ventilation using:
 Simple Adjuvants (Airways)
 Bag valve mask with reservoir
 LMA
 ETT
Illinois EMSC
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Fatal Chest conditions?
 Tension pneumothorax
 Open chest trauma
 Cardiac tamponade
 Flail chest
 Massive hemothorax
Illinois EMSC
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CIRCULATORY ASSESSMENT
 Carotid pulse (absent or present)
 Capillary refill
 Skin color
 Skin temperature
 Sites of bleeding
Illinois EMSC
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CIRCULATORY INTERVENTIONS
If central pulse is absent, begin
CPR
Apply direct pressure to open
wounds
IV access (2 wide bore cannulae14/16G).
 Fluids (colloids Vs crystalloids) 20ml/Kg
Peripheral Vs central line?
21
Dysfunction of the CNS
Aims
 Rapid neurological
assessment
• Alert; Voice; Pain;
Unresponsive
• Pupils
 Mini-neurological
assessment
• GCS score / AVPU
• Pupils
• Lateralising signs
• Blood sugar
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Exposure and environment
Aims
 Remove clothing to allow examination of entire
patient
 Care when removing tight trousers
 Prevent hypothermia
 Patient dignity
 Remove spine board
Don’t Forget The Back
Pause & check
 Are all immediately life-
threatening injuries
identified?
 Is all monitoring in
place?
 Investigations ordered?
 Analgesia?
 Relatives informed?
 Non-essential team
members disbanded?
The well practiced
trauma team should
aim to complete the
primary survey in
less than 10 minutes
Illinois EMSC
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Radiology
 Once the patient is stabilized the patient is sent to
radiology for the survery:
 Cervical spine X-ray (AP and lateral view)
 Chest X- ray (Rib cage)
 Pelvis X-ray
 Abdomen and Pelvis U/S
 CT brain is ordered if there is suspicion of head
trauma
 X-ray of extremities if fracture is suspected.
Chest X-Ray
Part 2 case
 Patient returned form the radiology department
complaining of severe chest pain and could not lay
down on his back for suturing of the cut wound in the
forehead
 Patient received the following medication:
 1500 cc of normal saline
 cefoperazone 1.5 gm IV
 Analgesia as Perfalgan 1gm IV followed by Pethedine 50
mg IM
 Labs were send for urgent Hb
 Patients Vital signs were:
 HR: 120/min
 Blood pressure 85-90/50-60 mmHg.
 CRT 2 sec
 SpO2:92 % On Room air.
 Patient still complains of severe chest pain and
received another 50 mg pethedine over 100 cc Normal
Saline over 30 min
Differential
Diagnosis
 What Labs to order?
 What other radiological investigations to
ask for?
 What other medications to give?
Chest X-Ray
Mediastinal widening
•Double aortic knob sign the right
•Diffuse enlargement of •Pleural effusion
the aorta
•Pericardial effusion
•Tracheal displacement to •Cardiac enlargement
•Left apical opacity
•Fractured first or second
ribs
CT chest
Aortograghy
Aortograghy
Final Diagnosis
Traumatic aortic tear
Traumatic Aortic Rupture
 These are found in victims of high-speed motor vehicle
crashes and falls from great heights, and 85% of these
injuries are due to blunt trauma.
 The majority (80-90%) of the patients die at the scene of
the accident from massive blood loss. Of the patients
reaching hospital alive, only 20% will survive without
operation.
 The mortality remains high even after surgery.
 In cases of aortic rupture, the clinical presentation
depends upon the site of injury. Patients with injury to
the intrapericardial portion of the ascending aorta will
usually develop a cardiac tamponade.
 Extrapericardial ascending aortic injury produces a
mediastinal haematoma and a haemothorax, usually
on the right side
 Rapid deceleration is believed to be responsible for
damage to the aorta that most commonly occurs in
the region of ligamentum arteriosum, just distal to
the origin of left subclavian artery.
 Patients may show transient hypotension, which
responds well to fluid therapy and further clinical
signs may be absent.
 This may delay the diagnosis with catastrophic
results should the aorta rupture completely. Thus a
high index of suspicion should be kept in mind.
 Aortic disruption should always be suspected in
patients with profound shock and who have no other
external signs of blood loss and in whom mechanical
causes
of
shock
(tension
pneumothorax
pericardial tamponade) have been excluded.
and
 Symptoms (if the patient is conscious) may
include:
 Severe retrosternal pain
 Pain between the scapulae
 Hoarseness of voice (pressure from haematoma
on the recurrent laryngeal nerve)
 Dysphagia
 Paraplegia or paraparesis
Aortic dissection Vs ACS.
 The definitive investigation of choice is angiography or
a CT angiogram of the aortic arch, the choice
depending on local policy.
 Survival in patients who have their injury repaired
surgically and who have remained haemodynamically
stable during the repair is 90%.
 Minimally invasive repair using aortic stenting
techniques are also being used
MANAGEMENT OPEN
PNEUMOTHORAX
 Ensure adequate airway
 100% oxygen
 Seal open wound
 Load & Go
 IV access en route
 Notify Medical
Direction
Courtesy of David Effron,
M.D.
SEALING THE OPEN WOUND
Asherman chest seal is very effective
SEALING THE OPEN WOUND
You can use impervious material taped on three sides
TENSION PNEUMOTHORAX
MANAGEMENT
TENSION PNEUMOTHORAX
 Ensure adequate airway
 100% oxygen
 Needle decompression if indicated
 Load & Go
 IV access en route
 Notify Medical Direction
MCQ
1.
Which of the following is true in regards to a
traumatic aortic rupture?
A. There is a 50% survival rate
B.
Immediate defibrillation is indicated
C. Usually due to deceleration injury
D. They are easily diagnosed in the pre-hospital
setting
3. What is the MOST likely abnormality that would be
seen on chest x-ray in a patient with traumatic rupture
of the aorta after blunt injury?
(A) Obscuration of the aortic knob
(B) Deviation of esophagus to the left
(C) Fracture of the first or second rib
(D) Apical cap
(E) Superior mediastinal widening
3. Male patient with intracerebral hemorrhage
and intra-abdominal bleeding, the optimum
blood pressure for this patient should be
maintained around:
A. 90 mmHg.
B. 100 mmHg.
C. 110 mmHg.
D. 70 mmHg.
4. The initial management of a poly-trauma patient should
include the following order:
A. Conscious level, secure airway, assess circulation , control
cervical spine, assist ventilation and exposure.
B. Secure airway, control cervical spine, assess circulation,
follow up conscious level and assist ventilation and
exposure.
C. Secure airway, control cervical spine, assist ventilation,
assess circulation, follow up conscious level and
exposure.
D. control cervical spine , secure airway, assist ventilation,
assess circulation, follow up conscious level and
exposure.
5-Which of the following is the BEST screening test for
detecting traumatic aortic injury in a stable patient?
(A) Chest radiograph.
(B) Computed tomography aortography.
(C) Trans-thoracic echocardiography.
(D) Test for unequal blood pressures in the upper
extremities..
Recommendations
 All Trauma patients should be assessed using the universal
AcBCDE approach.
 Management of Poly-trauma should include primary and
secondary survey.
 Team work is standard in management of trauma patients.
 Routine investigation should be implemented as a protocol
for our policy in Demerdash and ASUSH.
 High index of suspicion should be kept for aortic trauma in
any posttraumatic chest pain.
QUESTIONS?
THANK YOU

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