Polytrauma patient

I. Inform the hospital with the RTA

‫اٌسبخٗ ِؼ خب٘ضح‬ٚ ٗ‫ِٕتفبخئؼ ثبٌسبدث‬ٚ ُ‫ض اٌتي‬ٙ‫اُ٘ زبخٗ عؾبْ ٔد‬ٚ ‫ي‬ٚ‫ا‬
II. Prepare the polytrauma team (ER – surgery – anesthesia –cardiothoracic )
- allocate the tasks
surgical airway ‫ يفتر‬ٚ‫الف عبسف يتيت ا‬ٚ ‫اتبوذ ِثال ٔبيت اٌتخذيش اي‬ٚ ‫ازذ‬ٚ ً‫بَ عٍي و‬ٌّٙ‫صيع ا‬ٛ‫ت‬
ِٕٗ ‫ِىٕؼ يٕذٖ ًٌ اعٍي‬
- prepare : air way ( from suction to surgical airway ) , crash car , pelvic pinder
ٗ‫ اتجٍغت ثتفبصيً اٌسبدث‬ٌٛ cricothyrodotomy ًّ‫ِعبٔب زذ يعشف يع‬ٚ ‫اع تسغجب ًٌ خبي‬ٛٔ‫اال‬ٚ َ‫ض وً االزدب‬ٙ‫خ‬
‫٘ىزا‬ٚpelvic binder ‫ض ٘يستبج‬ٛ‫ زذ داعتٗ عشثيٗ ف اٌس‬ٌٛ. ٗ‫لع اي ٘ستبخ‬ٛ‫ات‬
III. Full PPE
‫ازّي عيٕه‬ٚ ‫ع تتعبًِ ِع اٌدشذ ِجبؽشح اٌجظ خالفض‬ِّٕٛ ‫ِّىٓ يجمي ِعذي اللذس هللا‬ٚ َ‫ْ فيٗ طشطؾٗ د‬ٛ‫لع ٘يى‬ٛ‫ات‬
َ‫ب اٌذ‬ٍٙ‫ص‬ٛ‫ي‬
IV. 5 sec / 1ry survey :
head to toe exam. ‫ثيجمي‬ٚ second ٗ‫عؾبْ في‬1st survey ‫ثعًّ اٌتالت اٌسدبت ف اي‬
1) External catastrophic‫ يعٕي خشذ وجيش يتجعٗ ٔضف وتيش ِؼ ِدشد لطع عبدي‬Hge
2) Cardiac arrest or not by algorithm
3) Airway obstruction ( modified ABC “ look listen feel
)ٗ‫ثغشع‬ٚ ‫لت‬ٌٛ‫وٍٗ ف ٔفظ ا‬ٚ ‫ديفيذ‬ِٛ ٖ‫أي ٕ٘ب خّغٗ ثظ عؾبْ وذ‬ٛ‫ف اٌعبدي وٕت ثعذ عؾش ث‬
V. Information from the paramedics : ُٙ‫اٌّغعفيٓ ٔفغ‬ٚ ‫ٖ ٌالععبف‬ٍٛ‫ِٓ اي ٔم‬
- mode of trauma
- AMPLE , Allergy, Medication, Past medical history, Last meal & Family History

Airway and c-spine immobilization

ٗ‫عت‬ٛ‫ثيضغظ صي اٌغ‬spine ‫اويذ زصً وغش ف اٌفمشات اٌعٕميٗ الْ اي‬ٚhigh risk ‫لع ِغبفٗ اوتش ِٓ ِتش يعتجش‬ٚ ‫ زذ‬ٌٛ
ًّ‫لع اٌتمً وٍٗ ف ساعٗ اويذ ٘يذؽ‬ٚ ٌٛٚ ٖ‫وذ‬
• Airway : patent or not
• C-spine immobilization :
- to avoid nerve injuries that supplies diaphragm , UL, LL
- MILS ( MANUAL INLINE STABLIZATION ) until neck collar stabilization
‫يفمذ‬ٚ ‫صً ايبن تؾيً ايذن اٌعيبْ ِّىٓ يديٍه عٍيُ تطٍعٗ ثؾًٍ سثبعي‬ٛ‫ ِي‬neck collar ‫تفضً ِثجت ايذن ٌسذ اي‬
!‫لف عضالت اٌتٕفظ‬ٛ‫ت طجعب ِٓ ت‬ّٛ‫٘ي‬ٚ ‫اٌجشاص‬ٚ ‫ي‬ٛ‫اٌتسىُ ف اٌج‬
 ‫ص‪ٛ‬سح ا‪ٚ‬ضر ِٓ اٌّسبضشح‬
‫اخٍي ثبٌي ‪ٚ‬أب ثشوت ‪ collar‬ثعًّ ‪ MILS‬ثشدٖ ٌسذ ِيتٍف ز‪ٛ‬اٌيٓ اٌشلجٗ دايش ِيذ‪ٚ‬س اثمي اؽيً ايذي ف االخش‬

‫وً دٖ ‪ MILS‬ثذسخبتٗ اٌّختٍفٗ اٌي اْ ي‪ٛ‬فش ‪NECK COLLAR‬‬

Breathing
• RR
• Pattern of breathing
• Auscultation
‫اُ٘ تالتٗ ٕ٘ب‬
• Tenderness
• Crepitus/ surgical emphysema: airway disruption by examine both chest and neck
‫ي‬ٚ‫لت ٌّب طٍع اٌشلجٗ فٕفسص االتٕيٓ ِٓ اال‬ٚ ‫ا خذ‬ٌٛٙ‫تديٍه ثعذ٘ب ثّذٖ ٔتيدٗ اْ ا‬ٚ ٌٗ‫ِّىٓ تّؾي اٌسب‬
• Click : rip fracture

Circulation
• Central pulse
• Peripheral pulse : shocked or not
• CTR
• BP
 Catheter
 2wide pore canula
 ECG
 E-fast (extended focal ascended sonography for internal bleeding)
- free fluid : pericardium effusion ‫ِيب‬
 spleen/kidney : hge َ‫ د‬ٚ‫ا‬
 external bleeding :
*pelvis: 1.5-2 l
*Abdomen : pain –tender – rebound – rigid –grey –Cullen
*Long bone : femur:1l tibia/ fibula .5l
 Long bone traction : decrease ( pain – bleeding )
score3# ‫ اي‬ٌٛ ‫لته ف عًّ االؽعٗ عٍي اٌّخ زتي‬ٚ ‫اُ٘ ِٓ تضيع‬
#‫ت‬ّٛ‫ ي‬unstable pelvis ‫اي‬
#‫ت‬ّٛ‫ِّىٓ ي‬ٚ ‫ن‬ٛ‫ يعًّ ؽ‬long bone fracture ‫اي‬
Abd hge= ‫ق‬ٛ‫ب ِٓ اٌعالِبت اي ف‬ٙ‫ثٕعشف‬ٚ ‫عٍّيبت االؽعٗ تغتٕي‬
shock and massive brain ً‫يسص‬ٚ ٖ‫ازذ‬ٚ ‫لته ف االؽعٗ ٘يٕضي ِشح‬ٚ ‫ضيعت‬ٚ score 11 ‫ خبيٍه‬ٌٛ
damage.
1st sign of shock = tachycardia # Do not count on BP
Disability
• GCS
• Pupil
• Random
• Temp

Exposure
• Segmental exposure: to avoid hypothermia as it affects the coagulation process and increases the
hge #‫ت‬ّٛ‫ثت‬
More hypothermia more coagulation deficit
• Log roll :
- early in : bleeding ( stab wound- penetrating wound- gun shot )
- late in: pelvic farc. Or even suspected ٗٔٛ‫ ِتى‬ٌٛ ٗ‫٘تسشن اٌدٍط‬
- or in surgery
• Drug marks
 Chest trauma
1) cardiac tamponade:
‫لف عٍي زبختيٓ المده والكميه‬ٛ‫إٌتيدٗ تت‬effusion ً‫ي زبخٗ ٌّب ثيسص‬ٚ‫ا‬
‫ وُ صغيش ثطئ‬-‫ وُ وجيش ثطئ‬-‫ عشيع وُ صغيش‬-‫ عشيع وُ وجيش‬:‫ا وبٌتبٌي‬ٛ‫اٌتشتيت ِٓ االع‬ٚ
ٖ‫وذ‬ٚ ٖ‫اٌىُ ِّىٓ وذ‬ٚ ٗ‫ْ ف زبدثٗ اويذ اٌّذٖ عشيع‬ٛ‫ٌّب او‬
blunt trauma if there’s bleeding tendency ٓ‫ِّى‬ٚ penetrating trauma ِٓ ‫ف اٌغبٌت يٕتح‬
ٌٗ‫ف اٌسب‬ٚ restriction of movement ً‫يسص‬ٚ ٗ‫ط ثبٌدٍط‬ٛ‫اٌمٍت يتس‬ٚ ‫اٌذَ ثيٍّي اٌّىبْ ثظ ِفيؼ زشوٗ فيتدٍظ‬ٚ ‫ِب‬ٚ‫زصٍت اٌتش‬
‫ب‬ٍٙ‫اؽي‬ٚ ‫دي ِؼ ٘يطٍع ثبٌغشٔدٗ الصَ اتذخً خشازيب‬
‫٘يديٍي اٌجيؾٕت ثبيٗ؟‬
congested neck veins , BP drop, tachycardia, artrial ‫فيدي ة‬veins ‫د ع‬ٌٛ ًّ‫اٌمٍت ِؼ عبسف يضخ اٌذَ اي خبيٍٗ فيع‬
constrition
# Beck’s triad (in 30% of cases) = congested neck veins, hypotention, distant (muffled) heart sound
 MCQ: penetrating trauma in neck, chest , upper abdomen = tamponade

- Dangerous sites: between nipples, between clavicle, xiphisternum

- On E-FAST there’s pericardial effusion
- TTT: fluids, operation, do pericardiocentesis if not available
- Complications of pericardiocentesis:
NV plexus injury-pneumothorax-lung laceration-cardiac trauma-coronary injury

2) Tension pneumothorax

₋ Mode of Trauma :
Blunt> penetrating ( with frac. Rib)
₋ Pathophysiology:
 In inspiration there is a –ve pressure
causing the valve to open
 In expiration there is a +ve pressure
causing the valve to close
‫ا‬ٌٛٙ‫يعٕي ا‬one directed valve ٗٔ‫ساوظ ثيؾتغً وب‬ٛ‫ث‬ِٛٛ‫إٌي‬
collapse ‫اٌشئٗ ت‬ٚ tension ‫يجمي‬ٚ ‫ط‬ٛ‫ا اٌّسج‬ٌٛٙ‫٘ىزا ٌسذ ِيضيذ ا‬ٚ 50 ‫ يخشج‬05 ً‫ دخ‬ٌٛ , ‫اي دخً ِؼ وٍٗ ثيخشج‬
Shift to opposite site, tamponading, venous congestion, hypoperfusion
₋ Signs and Symptoms: dyspnea – desaturated – tachycardia- no air entry on affected side –
resonance – mediastinum shift
₋ Management:
 Thoracostomy + tube 5th intercostal space MCL just 1cm anteriorly
‫ق اٌضٍع‬ٛ‫ب ِجبؽشح=ف‬ٙ‫ق اٌضٍع اي تست‬ٛ‫ إٌيشف ٌىٓ ف‬ٚ‫ اٌفيٓ ا‬ٚ‫سػ االستشي ا‬ٛ‫ب عؾبْ ِتع‬ٙ‫ِجتخؾؼ ف اٌغجيظ ٔفغ‬
‫اٌغبدط‬
Complications: injury( nerve, artery, pleura, lung, heart, spleen, liver)
 Needle thoracostomy 2 nd ICS MCL

3) open pneumothorax
‫ا‬ٛ٘ ‫ب فشاغ ثيغشة‬ٙ‫اٌي‬ٛ‫ ِؾيٍٕب٘بػ ز‬ٚ‫اء ؽيٍٕب٘ب ا‬ٛ‫ ضشثٕب عىيٕٗ ع‬ٌٛ
‫ْ ايٗ؟؟‬ٛ‫ِب ٕ٘ب الصَ تى‬ٚ‫يجمي اٌتش‬decompression ًّ‫اٌسً تع‬ٚ ٗ‫ا ِيعشفؼ يخشج فيمفً ع اٌشئ‬ٛ٘ ‫يك فذخٍت‬ٙ‫خذت ؽ‬
hemo-pneumo ْٛ‫غبٌجب ثيى‬ٚtension ‫خٍي ثبٌه الصَ تعبٌدٗ صر عؾبْ ِيمٍجؼ‬ٚpenetrating
shocked without congested neck veins? If U injured SVC or IVC# ْ‫س عبي ً٘ ِّىٓ يجمي اٌعيب‬ٛ‫اٌذوت‬
TTT: 3 sided occlusive bandage
‫ا اٌذسيغٕح يٍضق‬ٛ٘ ‫ ؽفظ‬ٌٛdressing and skin ‫ا اٌضيبدٖ ثيجمي ٌضق ِغطي‬ٌٛٙ‫ذ يطٍع ا‬ٛ‫ازذ ِفت‬ٚٚ ٍٗ‫أت ِمف‬ٛ‫تالت خ‬
#ٗ‫ا يجمي وذٖ عىغت اٌعٍّي‬ٌٛٙ‫ا اٌذسيغٕح ثعذ فطٍع ا‬ٛ٘ ‫ف اٌدذاسخشج‬
‫ا يٍضق ف اٌدشذ‬ٛ‫ا فتخٍي اٌذسيغٕح يتؾذ ٌد‬ٌٛٙ‫ا اصال؟ عؾبْ اٌفتسٗ تست ِٕٗ تؾفظ ا‬ٌٛٙ‫طت ٌيٗ اٌذسيغٕح ثيخؼ ِع ا‬
#ٗ‫فمفٍت‬
definitve ttt thoracostomy not throw existing wound#
‫ف‬ٚ‫ب ف خشذ ِؼ ِعش‬ٍٙ‫ا ثذي ِبدخ‬ٛ‫اثمي عبسف عّمٗ ِٓ خ‬ٚclean ‫ف خشذ أب عبٍِٗ عؾبْ يجمي‬tube ‫ارا الصَ اسوت‬
‫ب‬ٙ‫ثتتغبي في‬ٚ ِّٗٙbronchus ‫س‬ٛ‫اع‬ٚ ٗ‫عّم‬
#ُ‫ ف اٌدشذ اٌمذي‬open pneumothorax ‫ ف‬tube ً‫عي تذخ‬ٚ‫ا‬

4) Massive hemothorax
 1500 ml or 200ml/4h while applying chest tube ‫اخشي عٍّيبت‬
 Commonest penetrating if aortic disruption ‫ب‬ٙ‫٘يفطظ ف عبعت‬

 Internal thoracic & inter costal arteries#

 No congestion , no c. neck veins #‫ثيٕضف ثغضاسح‬
 Decrease air entry ‫فشلٗ عٓ اٌتٕؾٓ ثبي‬auscultation ‫ٕ٘ب‬dullness ‫ٕ٘بن‬hyper resonance
 TTT: decompression and blood transfusion
‫ازٕب ِّىٓ ٔجذا ثيٗ ٌسذ اٌذَ ِيدي‬saline ‫ض دَ ِؼ‬ٛ‫أت ثتٕضف دَ ع‬
 5) flail chest:
Blunt trauma resulting in two or more ribs being fractured in two or more places

Mode of trauma : Blunt trauma usually

# ٌُ‫ت ِٓ اال‬ّٛ‫وزا ضٍع اٌعيبْ ِّىٓ ي‬ٚ ‫ثغٓ ٔتيدٗ أٗ ِىغش‬ٚ ٗ‫ي‬ٛ‫اٌضٍع ثيخجظ ف اٌشئٗ وً ؽ‬
Symptoms : severe pain – click – tenderness – dyspnea – desaturated – rapid shallow breathing
ٗ‫ اتٕفظ ثعّك اٌضٍع يشصع ف اٌشئ‬ٌٛ

TTT: analgesia ‫ي‬ٛ‫طٍعع ِخذسات عٍط‬

Complications :Usualluy associated with lung contusion = restricted fluids ‫ اديت دخٍت‬ٌٛ pulm.
Edema
 Indication of ETT and ventilation in flial : type 1-2 resp. failure – pao2 <55 – paco2 >45
ٗ‫ق يّٕع خجطٗ اٌضٍع ف اي سئ‬ٛ‫ا يطٍع ٌف‬ٌٛٙ‫ا فىً ا‬ٛ٘ ‫ثىجظ‬
ABG done in flail chest #

6) Airway disruption

 Death at scene due to

suffocation
 Massive pneumothorax +
surgical emphysema
suspect disruption #
 Ttt: surgical repair
Bronchoscopy