LA CONSOLACION UNIVERSITY PHILIPPINES

SURGERY II

CASE DISCUSSION ON THE

MULTIPLY INJURED PATIENT

GROUP 4 - COURAGE
 TASKS
1. Apply the Four-step Triage Criteria
2. Assess the injuries of the patient, obtain trauma scores and
prognosis
3. What is the Trauma Alert Level of this patient?
4. What maneuvers can be done in the prehospital stage? How will
you clear the patient for transport?
5. Prioritize your suggested surgical procedures/maneuvers.
6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient
CASE
A 67-year-old male is brought in after a motor
vehicle crash into a stationary pole. Two other
passengers died in the field; the patient was
thrown out approximately 15 feet (4.6 meters)
away from the damaged vehicle. Patient is
reported to have lost consciousness for about
5-10 mins. He is taking aspilet 80mgs, metformin
500mgs and Gliclazide 60mgs.
At the ER, he was confused but follows
commands, can swallow and verbalize. He
complains of neck and nape pains and severe
pain on his right chest. Right arm is deformed
with tenderness and crepitus. Other extremities
have normal range of motion.
Vital Signs
BP 130/80 mm Hg P 122 bpm
RR 29 cpm T 37.3 C
O2 Sat 93% CRT >3 sec
All pulses intact
Flaring of the alae nasi noted. No stridor, oral
injuries or venous congestion noted in the neck.
Pupils reactive to light and accommodation.
Swelling and tenderness over right midaxillary
region; chest with crepitus, paradoxical
respiration and decreased breath sounds. No
murmurs, regular rhythm.
Abdomen is globular with voluntary guarding;
epigastric tenderness with rebound tenderness
on deep pressure
1. Apply the Four-step Triage Criteria.

Step One: Physiologic Criteria

Step Two: Anatomic Criteria
Step Three: Mechanism-of-Injury Criteria
Step Four: Special Considerations
 Physiological Criteria
Measure the vital signs and level of consciousness
Glasgow Coma Scale (GCS) <14
GCS 14 (X)
Systolic Blood Pressure <90
SBP 130 mmHg (X)
Respiratory Rate <11
12 (X)

PROCEED TO STEP 2 (Assess Anatomy of Injury)

 Assess Anatomy of Injury – Anatomic Criteria
All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee
Flail Chest
Combination trauma with burns
Two or more proximal long-bone fractures
Pelvic fractures
Limb paralysis
Amputation proximal to wrist and ankle

TRANSPORT TO A TRAUMA CENTER

 Mechanism of Injury Criteria:
Motor vehicle crash
The patient was thrown approximately 15 feet (4.6 meters) from the vehicle.

Special Considerations:
The age of the patient (67 years old), which may influence the physiological response to
trauma.
The patient is taking medications (aspilet, metformin, gliclazide) that may affect the
management and response to trauma.
2. Assess the injuries of the patient, obtain trauma
scores and prognosis.
Primary Survey (ABCDE) GCS:
Airway - no signs of airway obstruction because patient Eye Opening = (4)
can swallow and verbalize Verbal Response = confused (4)
Breathing - severe pain on right chest, chest with Motor Response = follows command (6)
crepitus, decreased breath sounds, paradoxical E4V4M6 = 14
respiration (flail chest, possible rib fracture), 02 Sat 93%
Circulation - CRT >3 sec (delayed), PR 122 (tachycardia) Revised Trauma Score:
Disability and neurologic status - Loss of consciousness GCS = 14 (4)
for 5-10 mins, (+) Confused but follows commands SBP = 130 mmHg (4)
Exposure, Environment - T: 37.3 C, Lost consciousness for RR = 29 cpm (4)
5-10 mins, (-) Skull fracture, (-) Headache, nausea, Total = 12
vomiting
3. What is the Trauma Alert Level of this patient?

Trauma alert level II

Trauma patient >65 years old or known history of anticoagulant use
Loss of consciousness greater than 5 minutes
Major MVC; Separation of rider from bike
Death of an occupant in the same vehicle
Two or more long bone fractures (Possible right ulna with radius fracture)
4. What Maneuvers can be done in the Prehospital
stage? How will you clear the patient for transport?

Assess scene safety prior to providing assistance and Remove the patient from dangerous situations.
Initiate basic life support (BLS).

Perform life-saving interventions Start with primary survey ABCDE survey with simultaneous neuroprotective measures to prevent or
to minimize secondary brain Injury.

Airway opening maneuvers -Look for signs of respiratory distress and airway impairment. Check the airway for any foreign
objects or injuries, such as burns, soot, or fractures to the face.
Hemorrhage control (e.g., use of tourniquets or pressure bandages)
Spinal immobilization-Use a cervical collar to immobilize the cervical spine. When managing airway, manually stabilize the
cervical spine.
Prehospital stage

Circulation Disability Exposure

Airway Breathing

Ensure that the Give Examine the entire

Provide immediate Identify life-threatening
airway is clear supplemental patient for signs of
hemodynamic support traumatic brain injury
and patent Oxygen (TBI), begin measures to
occult injury,
and hemostatic
Look for Asses Ventilation including the axilla,
measures while limit secondary brain
Perform Initial groin, and back.
indications of identifying sources of injury, and expedite
intervention Prevent and/or
respiratory bleeding, e.g., external definitive surgery if
identify chest indicated. manage
distress and hemorrhage, thoracic
injuries ( Tension Perform Neurological hypothermia with
airway cavity, abdominal
evaluation, calculate for rewarming
pneumothorax, cavity, thighs,
impairment. GCS, Assess pupillary techniques.
Flail chest retroperitoneal space.
stabilize cervical light response.
spine Assess motor and
sensation functions
5. Prioritize your suggested surgical
procedures/maneuvers.

ENDOTRACHEAL INTUBATION
-Flaring of alae nasi is an indication of respiratory distress to secure clear airway and ensure adequate oxygenation and ventilation.

NEEDLE DECOMPRESSION
-Possible pneumothorax (flial chest and crepitus of the chest)

ABDOMINAL CT SCAN AND EXPLORATORY LAPAROTOMY

-Globular abdomen woth voluntary guarding, epigastric tenderness with rebound tenderness with rebound tenderness on deep palpation could be
indicative if intre-abdominal bleeding.

OPEN REDUCTION AND INTERNAL FIXATION

Right arm is deformed with tenderness and crepitus could either be fracture or dislocation. The reason for open reduction and intrrnal fixation is
crepitus is sn indication of joint involvement.
6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.
Laboratory Exams to Request
CBC, Platelet Count
To monitor the patient’s hemoglobin and hematocrit to prevent any complications of possible bleeding
BUN, Creatinine, SGPT, SGOT and Electrolytes
To assess the status of his vital organs and to prevent complications of fluid and electrolyte imbalance
Capillary blood glucose
Because the patient is taking metformin, we will request this to measure and assess his glucose levels immediately
6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.

Management and Diagnostics for Tension Pneumothorax and Flail Chest

Diagnostics:
Chest X-ray - To check for tension pneumothorax, massive hemothorax or pneumoperitoneum. To confirm and
assess any sign of rib fracture as we suspect a flail chest in the patient as shown in his PE.
Cervical X-ray - To confirm and assess any sign of fracture causing the patient’s neck pain.
Pelvic X-ray - To confirm and assess any sign of fracture or dislocation
Right Arm X-ray o confirm and assess any fracture in the right arm which was seen to be deformed with tenderness
and crepitus
 6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.

Management and Diagnostics for Tension Pneumothorax and Flail Chest

Diagnostics:
Abdominal Ultrasound
Quick evaluation of the abdomen for free fluid areas such as subxiphoid (cardiac tamponade), subhepatic/Morrison’s
pouch (bleeding from liver), peri-splenic area (bleeding from spleen or pelvis).

Electrocardiogram - to monitor the patient’s cardiac activity

Monitor urine output

Insert foley catheter - oliguria is part of the criteria for shock which is one of the things we should look out for.
 6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.

Management and Diagnostics for Tension Pneumothorax and Flail Chest

Diagnostics:
Additional imaging
Requests for CT-scan and MRI
Whole Abdomen CT- scan - for massive hemoperitoneum, pelvic fracture, solid organ injury, and detection of bleeding in
retroperitoneal area
Cranial Plain CT- scan - to confirm and assess brain hemorrhage in unstable trauma patient
MRI - If the patient is stable, best modality to evaluate spinal cord injury
.
 6. Design a management (diagnostic and therapeutic) algorithm
(include rationale for work-ups, if any) for this patient.

Management and Diagnostics for Tension Pneumothorax and Flail Chest

Management:
Pain management administer analgesics, preferably opioids to alleviate pain and improve respiratory mechanics
Thoracic stabilization
Apply chest binder to stabilize the flail chest and prevent paradoxical chest wall movement. This will help to improve respiratory mechanics and reduce
pain, preventing respiratory compromise
Flail chest
Place the patient immediately placed on 100% oxygen.
If the patient is in respiratory distress despite having been placed on oxygen, consider mechanical ventilation. Fluid resuscitation
Should be cautiously administered to minimize fluid overload risk
A lactated ringer's solution may be used
Tension pneumothorax
Perform immediate needle decompression by inserting a large bore needle into the 2nd intercostal space midclavicular line on the affected side.
THANK YOU