POLYTRAUMA

CASE PRESENTATION

DR FERDINAND
24/05/2022
 IDENTIFIER: O.C

AGE: 73 Years

BIO DATA
GENDER: Male

PMHx: HTN/Diabetes(self
diagnosed)
 HISTORY

• RTA- Pedestrian vs Tricycle on busy Highway

• C/O- ? Loss of consciousness
- Facial bruises
- Lt Chest wall Pain + diff. breathing
- Lt Shoulder/Elbow Pain
• CT brain – TBI( Acute haemorrhage)
• X-ray Chest – 3rd – 7th Ribs.
• X-ray Lt Shoulder – old Proximal left
humeral
-old ulnar .
• Abdomino-pelvic USS- normal findings.
 INITIAL ASSESSMENT
• RTA Pedestran vs tricycle 2/7 ago
• Obvious injuries are – L Rib fractures 3rd -7th
- L Elbow & injury? New
- R thumb injury
- L zygomatic arch fracture
- L Lateral orbital wall
fracture
- HI (acute intra-cranial
haemorrhage)
 RESUSC. PLAN

– FBC
– RBG
– EUCr
– Clotting Profile
– Urinalysis
– Continous ECG
mornitoring
– Chest
physiotherapy
– IM Dicoferac75mg
start + IV
Omeprazole 4omg
start
• IVF N/S 1L 8hrly
• Left Broad Arm
Sling
• For review by the
Ortho & Trauma
Surgeon
• Admit to the surgical
ward
 TRAUMA ASSESSMENT

• A – Airway Patent /self maintenance

• B – RR 22/m and saturation 96% .

• C – HR 100/m, BP 140/78.

• D- GCS 15/15.

• Facial injury-Lt Raccoon eye.

-Lt Elbow Pain & Swelling.
- Lt Chest Wall tenderness.
• CT whole spine
• Retrieve CT head image
from clinix
• Retrieve all images
• Resume chat
• Stop diclofenac
• Review Abdo USS
• X-ray R thumb (AP/Lat)
• General surgeon to review
• D/C IVF
• Give oxygen by Cannula 2L/min
• Chase all blood results
• Chase USS report
• Hourly GCS please
TRAUMA
SERIES
IMAGING
SUMMARY OF INJURIES
• Based on these
injuries patient was
reviewed by;
• CTS
• NEUROSURGEON
• T & O SURGEON
 SECONDARY SURVEY (ATLS)
ABDOMEN
For rigid and distended abdomen
• Four quadrant tap
• Diagnostic peritoneal lavage
• Ultrasound
• Laparoscopic examination

Any
Deterioration

Consider rapid surgical exploration

 SECONDARY SURVEY (ATLS)
PELVIS

Clinical assessment
X-ray
Stabilize pelvis with fixator/ clamps if urethral injury is
suspected – high up in prostate PR
blood in meatus perineal haematoma
TRIAL CATHETHER WITH
GENTLE MATTNIPULATION
Ascending urethrogram
FINE CATHETHER

LOTS OF LUBRICANTS IN OT
 SECONDARY SURVEY (ATLS)
SPINAL INJURY
Thorough sensory and motor
examination
• Prevent further damage in
unstable fractures
• Log rolling for full
neurological examination –5
people required
• Use a long spine board for
transportation
 SECONDARY SURVEY (ATLS)

EXTREMITIES
• Full assessment of limbs for assessment of
injury
• Always look for distal pulse & neuro-status
• Carefully look for skin & soft tissue viability
• Look out for impending compartment
syndrome
 SECONDARY SURVEY (ATLS)

EXTREMITIES
Mangled Extremity Severity Score (MESS)
based upon --
1. Skeletal/ Soft tissue group
2. Shock group
3. Ischemia group
4. Age group

If > 7, limb salvage is questionable

DEFINITIVE CARE PLAN (ATLS)

Multi-specialty approach
(Inter-disciplinary
management)

The most appropriate person in

charge is the General / Orthopedic
surgeon.
COMPLICATTIONS

• Tetanus
• A.R.D.S.
• Fat embolism
• D.I.C.
• Crush syndrome
• Multisystem organ
failure (M.S.O.F.)
 COMPLICATIONS
A.R.D.S.
• Tachypnoea
• Dyspnoea
• Bilateral infiltrates in CXR
Treated with mechanical ventilation CPAP with
or without PEEP
Glucocorticoids
Inhaled nitric acid
 COMPLICATIONS
Fat Emblolism
• Around 72 hours
• Tachycardia
• Tachypnoea
• Dyspnoea
• Chest pain
• Petechial haemorrhage
Treated with ------ mechanical ventilation
------ anticoagulants
------ fixation of fractures
 COMPLICATIONS
Disseminated intravascular coagulation
• Follows severe blood loss and sepsis
• Restlessness, confusion, neurological
dysfunction, skin infercation, oligurea
• Excessive bleeding
• Prolonged PT, PTT, TT, hypofibrinogenemia

Treatment – prevention and early correction and

shock
 COMPLICATIONS
Crush Syndrome
• When a limb remains compressed for many hours
• Compartment syndrome and further ischaemia
• Cardiac arrest due to metabolic changes in blood
• Renal failure
Treatment
• Prevention-ensure high urine flow during extrication
• IV Crystalloids, Forced mannitol alkaline diuresis
• Fascitomoy and excision of devitalized muscles
• Amputation
COMPLICATIONS
M.S.O.F
Progressive and sequential dysfunction of
physiological systems
Hypermetabolic state
It is invariably preceded by a condition known
as
Systemic Inflammatory Response Syndrome
(SIRS)
Characterized by two or more of the following
• Temperature > 38° C or < 36°
• Tachycardia > 90/ min
• Respiratory rate >20/min
• WBC count > 12,000/cmm or <4,000/cmm
COMPLICATIONS

M.S.O.F.
Treatment : Key word is
PREVENTION
• Prompt stabilisation of fracture
• Treatment of shock
• Prevention of hypoxia
• Excision of all dirty and dead
tissue
• Early diagnosis and treatment
of infection
• Nutritional support
 CONCLUSION

High velocity trauma is aptly called

neglected stepchild of modern
civilisation being the number one
cause of death in 18 to 34 years age
group. Despite the major economic
productivity losses due to this problem
injury receives < 2% of the total
health budget allocation. Adequate
funding & legislations must be passed
to reduce the enormous impact on the
society.