144

POLYTRAUMA
Abstract: Polytrauma or a multiple injured patient is defined as one who has injury to two or more organ systems in the body. It is important to recognise this condition because it is life threatening and delay in treatment can be fatal. The primary objective is quick early assessment and resuscitation as time is the most important factor here. Once patient is stabili ed! the treatment to the injuries can be done according to the priorities of the systems. It has been suggested that "#$ of all death from polytrauma are medically preventable.% Polytrauma patients are categori ed using Triage system. Case Report: & %'(year(old man was admitted to casualty with history of a motor vehicle accident. )e had lost consciousness for about * minutes. )e also complained of severe abdominal pain and had pain on moving his lower limb. On e+amination he was conscious and his ,lasgow coma scale was "*#"* . )e was pale and dyspnoeic. )is pulse was ""* per minute and blood pressure recorded was -'#./.Pulse o+imeter recorded an o+ygen concentration of -.0. )is head! neck and both upper limbs were normal. The chest spring and pelvic spring were normal. The respiratory and cardiovascular systems were normal. There was abrasion wound over the abdomen and part of his lower limbs. On e+amination! the abdomen was tense and guarded over the right hypochondriac region as well as the other region of the abdomen. 1owel sound was sluggish but there was no hematuria. The left thigh was swollen and tender over the middle. The range of motion of the right hip and knee was reduced. The knee and foot was normal. There was no neurology in the lower limbs.

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The patient was put on a head chart and splint was applied to his right lower limb. % intravenous lines were attained and patient was started on crystalloid solution. O+ygen was administrated via a ventimask at '20 .The full blood count! arterial blood gases and cross match was sent. 3(ray of skull and cervical vertebrae! chest erect! abdomen and pelvis with right lower limb was taken. Peritoneal lavage done confirmed bleeding intraperitoneally .)is +(ray showed a transverse fracture of his right femur at junction of upper and middle third. & diagnosis of cerebral concussion with closed fracture of right femur with intra abdominal organ injury was made and patient was planned for laparotomy and intramedullary fi+ation for his fracture. 4nder general anaesthesia! a midline laparotomy incision was made. &bdomen was opened in layers .& total of 522ml of blood was drained from the cavity .The liver shower a large laceration with active bleeding. The laceration was packed with gelfoam and the bleeding stopped .&ll other organs e+amined were normal. &drain was placed before the wound was closed in layers .6or the femoral fracture! it was fi+ed with a 7untcher nail with open method using a lateral skin incision. The deep fascia was cut and vastus lateralis retracted .The fracture site was debrided and washed with normal saline. The length of the nail was measured intraoperatively and reamed to si e "". The nail was inserted antegradely. The wound was washed and deep fascia closed after drain was inserted . 8kin was closed with dafilon %#2.Post( operative period was uneventful .)e was discharged after "2 days in ward with crutches. The fracture healed in ' months and he was back to full weight bearing. Discussion: The most common cause of polytrauma is road traffic accident. Others being a fall !sports injury ! natural disasters or by e+plosion . The patient no matter what type of injury is suspected! has to be e+amined fully. This involves multidisciplinary

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approach and for this reason polytrauma patients are best studied in different stages or periods. Tscherner conveniently divided it into ' stages i9 &cute or resuscitation ii9 Primary or stabili ation iii9 secondary or regeneration and iv9 tertiary or rehabilitation . - The acute phase is the first phase and corresponds roughly to the first $ hours. In this phase! the &1: ;airway and cervical! breathing and circulation 9 assessment is carried out .The primary goal is to make sure optimal o+ygenation !intravascular volume and cardiac function are maintained and neurology is assessed . The pulse! blood pressure! temperature! respiratory and cardiovascular systems are quickly assessed .The arterial blood gases ;&1,9 and chest + ray are done. &1, is very useful as an indicator for severity of the injury! assessment of shock and adequacy of resuscitation. <illiams reported in his study of %!.$" patients that a base deficit of = or > to (.is a marker of severe injury and significant mortality in all trauma patient particularly in patients ** years and older.
$

)owever they may also have significant injuries and

mortality without manifesting a base deficit out of the normal range. This can be e+plained by virtue that the skeletal muscle mass in elderly decreases! which is the primary source of lactate production. Other conditions that must be looked out for which can give a low o+ygen saturation are tension pneumothora+! haemopneumothora+ or flail chest. & chest tube should be inserted immediately. 8hock can be diagnosed by a rapid pulse rate! low blood pressure and low central pressure apart from low urine output and rapid respiratory rate. &ccording to it?s grading wheather type I or type I@! the need for blood transfusion vary. In type II! and I normally blood transfusion is not necessary. )owever in type III and I@! if blood is needed to be transfused urgently! O negative blood can be used .In life saving condition! whole blood is given! otherwise packed cell is preferred. <hile waiting for blood! crystalloidsolution like Ainger lactate is administered. Barge amounts up to $ liter may be given to young adults but in the elderly volume overload must be borne in mind. 8ome prefer to add bicarbonate to the solution. &ll these are administered via large bore needles e.g. si e "' or ".. Platelets are given when the

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count is less than *2 222. 6resh fro en plasma may be used to replace the loss of factor @ and @III. The resuscitation is controlled by monitoring the vital signs and urine output. In adults it is adequate if urine output is at least 2.* ml#kg #hr .In some cases the pulmonary arterial pressure or pulmonary wedge pressure is also monitored. If the circulation has been stabili ed but no urine output! post renal causes should be looked into and appropriate treatment started The neurological status is assessed using ,lasgow :oma 8cale ;,:89. It is the best predictor of the late outcome of cerebral injury. In assessing the patient! we must also check for the four primary refle+es ;tricep! bicep! patella and ankle9. Ceterioration in the neurological status or ,:8 ="2 is evidence of space occupying lesion or significant cerebral edema and a :T scan of the brain is warranted ./ Occasionally there may be an unstable patient who had a massive hemorrhage. The bleeding could be from head injury ! chest ! abdomen ! and pelvis or as a result of multiple fractures . In such patients the diagnosis procedures are limited to a9 plain chest +( ray b9 skull +( ray c9 lateral cervical d9 &P pelvis e9 ultrasound of the abdomen. :hest + ray and ultrasound abdomen can diagnose up to -*0 of all massive hemorrhage . Intracranial bleeding will require urgent :T scan and immediate e+ploration .The immediate and early evacuation of any significant epidural or subdural blood is mandatory as delay produces poorer outcome. Dinor intracranial lesions are kept under careful review since secondary epidural bleed may occur. :urrently diagnostic peritoneal lavage ;CPB9 and computed tomography ;:T9 are considered the standard modalities for evaluation of patients with blunt abdominal trauma ;1&T9. CPB which is about -2("220 sensitive is helpful in deciding on laparotomy in hemodynamically unstable patients.
5

:T with sensitivity of -.0 on

the other hand may provide precise information about the severity of the injury. )owever another diagnostic tool! ultrasonography ;489 for evaluating abdominal trauma has been widely used. &part form its noninvasiveness! it can be preformed rapidly. Eoshii reported in his study of "!%$- patients suspected of 1&T using 48 as

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diagnostic tool! he found 48 was -'..0 sensitive! -*."0 specific and -'0 accurate ."!"2 &mong organ sensitivity! he found liver to be most sensitive with sensitivity of -%.'0 and intestine least sensitive with sensitivity of $'.50. Overall :T is most superior but time consuming and 48 and CPB has about the same accuracy and sensitivity. )emothora+ requires a chest drain and based on the amount of blood loss through it ! thoracotomy may be warranted. Bikewise intraperitoneal bleed requires urgent laparotomy .In all cases! pelvic bleed must be ruled out and the origin of bleed must be evaluated before laparotomy .It is important to identify risk factors which increase chances of abdominal injury following blunt trauma e.g. depressed sensorium! base e+cess =(. mFq#l! major chest trauma! hypotension and pelvic trauma. ,rieshop found abnormal physical e+amination a significant risk factor in polytrauma. formula. Triage is another method of classifying patients according to need rather than order of arrival Triage means to sift or sort. The aim is to provide optimum care to ma+imum number of number of injured in order of importance. It is used in military medicine and natural disaster when the number of causalities e+ceeds the number of helpers. There are five categories. The first is red! for immediate treatment .The second is yellow! urgent treatment. The third green! delayed. The fourth is blue! e+pected and the fifth is white where the patient is already dead. This should be carried out by the most e+perienced person available .It could be approached anatomically! physiologically or by the mi+ed method. Cocumentation is by labels using color and te+t. There are two types: the single card e.g. Thomas labels and the cruciform systems e.g. :ambridge labels. The primary period is the first 5% hours after injury. It begins when all vital functions have been stabili ed. 8pecific injuries require more diagnostic procedure. These include further laboratory test. &dvance cardiovascular measurements are required especially in patients with prolonged shock phase and those with thoracic trauma.
*

In Injury 8everity 8core includes a scale that defines body area and a

code based on severity. Fach is given a number and severity is calculated using a

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Coppler ultrasound or angiography is done to e+clude specific vascular injuries. Injuries to urogenital systems can be e+cluded by retrograde cyctography. 6racture and joint injuries require skeletal radiography. The second priority injuries are also called delayed primary or day" surgery and they come ne+t. These include cerebral injuries! eye and facial injuries! progressive compression of the spinal cord! visceral injuries and musculoskeletal injuries .In cerebral injuriesG epidural and subdural haematoma takes second priority to massive hemorrhage .&ll other cranial injuries are treated during delayed primary phase .:T scan is indicated in primary unconscious patients ;,:8 =/9! focal neurological lesions! open brain injury! skull fracture and deterioration of ,:8. Perforating injuries and major facial lesion requires immediate operation in the primary period. 8imultaneous treatment of e+tremity fracture can be done. Progressive cord compression is an absolute indicator for operation. Aecovery depends on initial damage and contusion as well as mechanical factors e.g. fragments of bone and disc. Immediate stabili ation of spinal fracture protects the cord and allows early mobili ation of the patients. @isceral injuries may be life threatening if not diagnosed early. Aoutine test may be non(specific. Aupture of diaphragm is a rare injury in a polytrauma ;"0(509 and is often missed. :hest +(ray using contrast via nasogastric tube may be needed in doubtful cases. Baprotomy is indicated in /20 of cases. Injury to small bowel and mesentry occurs in $0(/0 of 1&T cases. Perforation may occur after several days and is diagnosed by peritoneal lavage. Besions of pancreas and duodenum are difficult to diagnose and require :T scan .)ematuria makes diagnosis of injury to genitourinary systems easy . In cases of musculoskeletal injuries! fracture fi+ation to achieve stable osteosynthesis is important so early mobili ation is possible. <here there is a vascular injury or compartment syndrome! it is treated first followed by fracture fi+ation .The most important prognostic factor in vascular injury in the ischaemic time interval and

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degree of any reperfusion disturbance. Duscle loses function after %(' hours of ischaemia and irreversible damage occurs after '(. hours whereas nerve loses function after $2 minutes and irreversible damage after "%("' hours. Aeconstruction of the vessel either direct or by temporary shunt is important to restore vascularity. The prone vessels are subclavian artery near the clavicle! brachial artery near the shaft of humerus! femoral artery near the shaft of femur and popliteal artery at the knee. There are *20 chances of popliteal artery rupture in knee dislocation. In treatment of soft tissue injury! primary closure is not important but it is necessary to cover the osteosynthetic material and bone .&ll dead and necrotic tissue is removed because hypo+ia delays and increases susceptibility to infection. Open fracture gets priority over close fracture but stable or temporary fi+ation is also important in close fracture. This is because a stable fracture causes less pain! less secondary soft tissue injury! less chance of fat embolism! less stress! less traumatic shock less respiratory distress syndrome ;&AC89 and less multiorgan failure. Pelvic and femoral fracture are associated with highest mortality and morbidity due to large space available for blood loss and associated injuries .It has been found that patients with thoracic trauma develop &AC8 more often if submitted to intramedullary nailing of long bones in %' hours than if operated secondarily. 1ut if there is no thoracic trauma! low incidence of &AC8 regardless of the timing of surgery. Tscherne suggested to prevent pulmonary failure after intramedullary nailing a9 primary stabili ation of the femur is a major goal in polytrauma b9 if pulmonary damage! avoid reaming.- 4nreamed nail could be used .c9 if patient is critically ill! use e+ternal fi+ator as a temporary method. &nother important aspect of limb injury is salvage or amputation. Dodern microsurgical procedure has made it possible to salvage a revascularised limb. 1ut judgement is difficult! individuali ed and difficult to quantify. Dangled F+tremity 8everity 8core ;DF889 is helpful in deciding the treatment. There are four parameters. 8keletal # soft tissue! shock! ischaemia and age. Fach of these has points in subcategories. Aetrospectively it has been shown that 5 points or more correlates well with decision to amputate the affected limb. &lso the prognosis is poor if warm ischaemia is H . hours with crush injury.

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4nstable pelvic fracture if involving the posterior ring will require a :T scan as soon as possible .6or anterior stabili ation! e+ternal fi+ator may be required but for displaced sacral fracture! internal fi+ation is needed. 4nstable injury to the spine with neurology is nowadays treated with operation. 6racture of cervical spine can be treated with )alo or continuous traction. Thoracolumbar spine injury is initially treated with a closed reduction and correction of alignment. Bater a posterior lateral decompression with transpedicular screw is done. 1urst fracture will require additional anterior fusion .In polytrauma patients a %(stage approach is used. Aarely unstable fracture of thoracic spine needs immediate treatment in primary period the second period is from $rd till /th day. This is the phase of regeneration. 8econdary deterioration of organ can be prevented by e+tensive debridement of necrotic tissue and septic foci and evacuation of haematoma .In this period second look debridement is done. <ounds are secondarily closed! soft tissue reconstruction done! definite treatment for facial fracture! osteosynthesis of upper e+tremities! forearm and comple+ joint reconstruction. Bocal flaps could also be done. Farlier it was believed that there was advantage of early fracture fi+ation in minimi ing morbidity in trauma patients. Aecently neurosurgeons have e+pressed concern regarding appropriateness of early fracture fi+ation after severe head injury. Iaicks et al in their study of $$blunt trauma cases with significant head injury found that early fracture fi+ation lead to greater fluid administration )ypo+ia and hypotension when present are risk factors for secondary brain injury and may contribute to poor neurologic outcome after early fi+ation. *On the contrary! Dc 7ee in his study of '. patients found that femoral fracture in a patient with concomitant head injury does not increase mortality or neurologic disability and supports early fracture fi+ation in these patients. . The last period is the tertiary period. This is roughly after / days. )ere the prognosis is apparent. 8ometimes organ dysfunction increases and isolated &AC8 develop. 6inal reconstructive operation is done .1y this time the patient should have definite haemodynamic stability and rehabilitation process can begin.

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6inally it should be remembered that the polytrauma patient is usually in an unstable condition and a sound judgement and team approach is required to manage him fast and effectively! as time is the limiting factor. References: ". Bode P.J. &bdominal ultrasound as a reliable indicator for conclusive laparotomy in blunt abdominal trauma . I. Trauma "--$G $':%5($" %. Bone L. :urrent concept review. The management of fracture in the patientswith multiple trauma . I. 1one Ioint 8urg. "-/.G./;&9: -'*(-'$. Davis Ja!es 1ase deficit in the Flderly: & marker of severe injury and death. I. Trauma. "--/G '*;*9 : /5$(/55 '. "ries#op $ A Jacobson L% .8elective use of :T and diagnostic peritoneal lavage in blunt abdominal trauma . I. Trauma "--*G $/ : 5%5(5$" *. Jaic&s RR Co#n 'M. Farly fracture fi+ation may be deleterious after head injury . I. Trauma "--5G '%;"9: "(* .. Mc (ee MD 'c#e!itsc# %). The effect of a femoral fracture on concomitant closed head injury in patient with multiple head injury. I. Trauma "--5G '%;.9: "2'"('* 5. Os*en +R. &bdominal paracentesis and peritoneal lavage in blunt abdominal trauma .I. Trauma "-5"G "" : /%'(%/. Tsc#erne ) Re,e* " . :are of the polytraumatised patient .I. 1one Ioint

8urg . "--.G 5/;19: /'2(*"

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-.

'c#urin& "+) . The value of physical e+amination in the diagnosis of patient with blunt abdominal trauma .& retrospective study. Injury "--5G %/: %."(./

"2.

Yos#ii ). 4sefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. I. Trauma. "--/G '*;"9: '*(*"

% $ / 5 " * * .