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 Table of Contents  
SYMPOSIUM - POLYTRAUMA MANAGEMENT
Year : 2013  |  Volume : 6  |  Issue : 1  |  Page : 7-12

Polytrauma management at the institutional level


1 Department of Trauma & Emergency, AIIMS, Raipur, Chhattisgarh, India
2 Department of Anaesthesia, AIIMS, Raipur, Chhattisgarh, India
3 Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India

Date of Web Publication23-Sep-2013

Correspondence Address:
Srinivasan Swaminathan
Department of Trauma & Emergency, AIIMS, Raipur - 492 099, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.118727

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  Abstract 

Polytrauma remains the leading cause of death and disability in children and young adults. Systematic organized team effort is essential for improving the survival in trauma victims. Initial assessment includes preparation, triage, rapid primary survey and resuscitation, secondary survey and definitive care. ABCDE of primary survey includes airway maintenance with cervical spine control, breathing and ventilation. Circulation and hemorrhage control, disability and exposure with prevention of hypothermia. Secondary survey includes head to toe examination of the trauma patient including a complete history and physical examination and reassessment of all vital signs. Definitive care may involve shifting the patient to radiology/operating room/intensive care unit.

Keywords: Definitive care, initial assessment, polytrauma management, primary survey, secondary survey


How to cite this article:
Swaminathan S, Neema PK, Agrawal AC. Polytrauma management at the institutional level. J Orthop Traumatol Rehabil 2013;6:7-12

How to cite this URL:
Swaminathan S, Neema PK, Agrawal AC. Polytrauma management at the institutional level. J Orthop Traumatol Rehabil [serial online] 2013 [cited 2019 Jan 21];6:7-12. Available from: http://www.jotr.in/text.asp?2013/6/1/7/118727


  Introduction Top


The term polytrauma has been defined in different ways by authors all over the world and a universal consensus needed for the definition. Polytrauma may be defined as injury to at least two body regions with [abbreviated injury scale-[Table 2]] ≥3 and with the presence of systemic inflammatory response syndrome on at least 1 day during the first 72 h. [1],[2] Polytrauma is a major cause of morbidity and mortality in both developed and developing countries. [3] And it remains the leading cause of death and disability in children and young adults. [4] The incidence and prevalence of polytrauma varies from region to region. The most common causes are road traffic accidents, fall from heights, bullet injuries, etc. [3] In civilian life, polytrauma is often associated with motor vehicle accidents. Polytrauma patients represent a major challenge to trauma care and the optimization of their care is a major focus of clinical research. The majority of mortality occurs within the 1 st h following trauma, often defined as "the golden hour." [5] Systematic organized management in the early hours is essential for improving survival among trauma victims.


  Initial Assessment Top


The treatment of seriously injured patients requires rapid assessment of injuries and initiation of life preserving therapy. Because time is precious systematic approach that can be easily reviewed and practiced is essential. This process is known as initial assessment and includes:

  1. Preparation
  2. Triage
  3. Rapid primary survey (ABCDE)
  4. Resuscitation [Table 1]
  5. Adjuncts to primary survey
  6. Consideration of need for patient transfer
  7. Secondary survey (head to toe evaluation and patient history)
  8. Adjuncts to secondary survey
  9. Continued post resuscitation monitoring and re-evaluation
  10. Definitive therapy.
Table 1: Therapeutic decisions based on response to initial fluid resuscitation (2000 ml of isotonic solution in adults)

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Table 2: AIS

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Preparation

Preparation for trauma patient occurs in the pre-hospital and hospital setting. In the pre-hospital phase emphasis should be placed upon airway maintenance, immobilization of patient and immediate transport to the closest appropriate facility. In the hospital setting advanced planning before trauma patient arrival is essential. Proper airway equipment should be organized, tested and placed where it is easily accessible. Warmed crystalloid fluids should be kept ready for infusion purpose. Appropriate monitoring facilities should be kept readily available.

Triage

Triage involves sorting of patients based on their need for treatment and the resources available for that treatment. It also pertains to the sorting of patient in the field and the decision regarding to which medical facility they should be transported.

Primary survey and resuscitation

  1. Airway maintenance with cervical spine control
  2. Breathing and ventilation
  3. Circulation with hemorrhage control
  4. Disability: Neurological status
  5. Exposure/environmental control: Completely undress the patient, but prevent hypothermia.


Airway maintenance with cervical spine control

Establishing and maintaining an airway is always the first priority. If a patient can talk the airway is usually clear, but if unconscious the patient will likely require airway and ventilatory assistance. Important signs of obstruction include snoring or gurgling, stridor and paradoxical chest movements. The presence of a foreign body should be considered in unconscious patients. Advanced airway management (endotracheal intubation, cricothyrotomy or tracheostomy) is indicated if there is apnea, persistent obstruction, severe head injury, maxillofacial trauma and a penetrating neck injury with an expanding hematoma or major chest injuries.

Cervical spine injury is unlikely in alert patients without neck pain or tenderness. Five criteria increase the risk for potential instability of the cervical spine: (1) Neck pain, (2) severe distracting pain, (3) any neurological signs or symptoms, (4) intoxication, and (5) loss of consciousness at the scene. A cervical spine fracture must be assumed if any one of these criteria is present, even if there is no known injury above the level of the clavicle. [6],[7],[8],[9] Even with these criteria, the incidence of the cervical spine trauma is approximately 2%. The incidence of the cervical spine instability increases up to 10% in the presence of a severe head injury. To avoid neck hyperextension, the jaw-thrust maneuver is the preferred means of establishing an airway. Oral and nasal airways may help maintain airway patency. While managing patients airway care should be taken to avoid excessive movement of the cervical spine. Hyperextension, hyperflexion or rotation of the neck should be avoided to establish and maintain patient's airway. Manual inline immobilization technique should be used to stabilize the cervical spine during laryngoscopy. [10],[11],[12],[13],[14],[15]

Unconscious patients with major trauma are always considered to be at increased risk for aspiration and the airway must be secured as soon as possible with an endotracheal tube or tracheostomy.

Breathing

Assessment of ventilation is best accomplished by the look, listen and feel approach. Look for cyanosis, use of accessory muscles, flail chest and penetrating or sucking chest injuries. Listen for the presence, absence or diminution of breath sounds. Feel for subcutaneous emphysema, tracheal shift and broken ribs. The clinician should have a high index of suspicion for tension pneumothorax and hemothorax. Rapid needle decompression should be performed in case of a tension pneumothorax, by insertion of a wide bore needle in 2 nd intercostal space in midclavicular line. Chest tube insertion should be performed in case of a massive hemothorax and pneumothorax.

Circulation and hemorrhage control

Hemorrhage is the most important cause of preventable death after injury. Hypotension after injury must be considered hypovolemic unless proved otherwise. Hemorrhage can be classified into four classes based upon the extent of blood loss as given below:



External hemorrhage is identified and controlled during the primary survey. Rapid external bleeding is managed by direct pressure on the wound. Pneumatic splinting devices also can help in controlling bleeding.

Definitive control of bleeding and rapid replacement of lost intravascular volume is important. Definitive control of hemorrhage includes surgery, angioembolization and pelvic stabilization in case of pelvic fractures. A minimum of two large caliber (of at least 16G) intravenous (i.v.) cannulas should be introduced. The maximum rate of fluid administration is determined by the internal diameter of the catheter and inversely related to the length and not by the size of the vein in which it is inserted. Establishment of upper extremity peripheral i.v. access is preferred. Other peripheral lines, central venous lines, cut downs should be used in accordance with the skill level of the treating physician.

At the time of i.v line insertion blood should be drawn for type and cross-match, baseline hematological studies and pregnancy test for all females of child bearing age. All i.v. solutions should be warmed either by storage in a warm environment (37-40°C or 98.6-104°F) or by usage of fluid warmers. Hypothermia is a potentially lethal complication of trauma.

Warmed isotonic electrolyte solutions such as ringer lactate and normal saline are used for initial resuscitation. This type of fluid provides transient intravascular expansion and further stabilizes vascular volume by replacing accompanying losses into interstitial and intracellular spaces.

An initial warmed fluid bolus is given as rapidly as possible. The usual dose is 1-2 L for adults. This often requires pumping devices (mechanical or manual) to the fluid administration sets. Patient's response is observed during this initial fluid administration and further diagnostic and therapeutic decisions are based upon this response. A rough guideline for the total amount of crystalloid volume required is to replace each 1 ml of blood lost with 3 ml of crystalloid. It is important to assess patient's response to fluid resuscitation and evidence of adequate end organ perfusion and oxygenation. The return of normal blood pressure (BP), pulse pressure and pulse rate and urine output of at least 0.5 ml/kg/h adequate perfusion. Changes in central venous pressure, serial measurement of base deficit and serum lactate can be used to monitor the response to therapy.

Fluid resuscitation and avoidance of hypotension are important principles in the management of blunt trauma patients especially those with traumatic brain injury. In penetrating trauma with hemorrhage delaying aggressive fluid resuscitation until definitive control may prevent further bleeding.

Disability (neurological evaluation)

A rapid neurological evaluation is done at the end of primary survey. This neurological evaluation establishes patient's level of consciousness, pupillary size and reaction, lateralizing signs and of spinal cord injury level. The Glasgow coma scale (GCS) [Table 3] is a quick, simple method for determining the level of consciousness that is predictive of patient outcome - particularly the best motor response. A decrease in the level of consciousness may indicate decreased cerebral oxygenation or direct cerebral injury. An altered level of consciousness demands immediate reevaluation of patient's oxygenation, perfusion and ventilation status.
Table 3: GCS

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Exposure (environmental control)

The patient should be completely undressed to facilitate a thorough examination and evaluation. After the patient's clothing has been removed and examination completed patient should be covered with warming blankets or external warming devices to prevent hypothermia.

Adjuncts to primary survey and resuscitation

Adjuncts that are used during primary survey and resuscitation phases include electrocardiographic monitoring, urinary and gastric catheters, arterial blood gas levels, pulse oximetry, end tidal carbon-di-oxide, BP, X-ray examination and diagnostic studies.

Considering need for patient transfer

During primary survey and resuscitation phase if the evaluating doctor has obtained enough information to indicate the need to transfer the patient to another facility the transfer process should be initiated immediately.

Secondary survey

The secondary survey does not begin until primary survey (ABCDE) is completed, resuscitation efforts are underway, and normalization of vital functions has been demonstrated. The secondary survey is a head to toe evaluation of the trauma patient that is a complete history and physical examination, including reassessment of all vital signs.

History
"AMPLE" is a useful mnemonic:

A - Allergies

M - Medications currently used

P - Past illness/past pregnancy

L - Last meal

E - Events/environment related to injury.

Physical examination: During secondary survey physical examination follows the sequence of head, maxillofacial structures, cervical spine and neck, chest, abdomen, perineum/rectum/vagina, musculoskeletal system, and neurological system.

Head

Entire scalp and head should be examined for lacerations, contusions and evidence of fractures. Since edema may preclude examination in later stages eyes should be re-evaluated for:

  • Visual acuity
  • Pupillary size
  • Hemorrhage of conjunctiva/fundi
  • Penetrating injury
  • Contact lenses
  • Dislocation of lens
  • Ocular entrapment.


Maxillofacial structures

Maxillofacial trauma that is not associated with airway compromise or major bleeding should be treated only after patient is stabilized completely and life-threatening injuries have been managed.

Cervical spine and neck

Patients with maxillofacial or head trauma should be presumed to have an unstable cervical spine injury and neck should be immobilized until all aspects of the cervical spine have been adequately studied and injury has been excluded. Examination of neck includes inspection, palpation and auscultation. Cervical spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal fracture can be discovered on a detailed examination. The carotid should be palpated and auscultated for any bruits.

Chest

Visual evaluation of the chest both anterior and posterior can identify conditions such as open pneumothorax and flail segments. Complete evaluation should be done with palpation of entire chest cage including clavicles ribs and sternum. Auscultation and chest X-ray were done to detect the presence of pneumo/hemathorax.

Abdomen

Abdominal injuries should be identified and treated aggressively. The specific diagnosis is not as important as recognizing that such an injury exists and initiating surgical intervention if necessary. Patients with unexplained hypotension, neurological injury, impaired sensorium secondary to alcohol and or other drugs, and equivocal abdominal findings should be considered candidates for peritoneal lavage, abdominal ultrasound (focused assessment sonography in trauma), or if hemodynamic findings are normal then computed tomography (CT) of abdomen.

Perineum/rectum/vagina

Perineum should be examined for contusions, hematomas, laceration and urethral bleeding. If a rectal examination is required physician should assess for the presence of blood within the bowel lumen, a high riding prostate, presence of pelvic fractures, the integrity of the rectal wall and quality of sphincter tone. Vaginal examination should be performed in patients at risk of vaginal injury.

Musculoskeletal system

The extremities should be inspected for contusions and deformities. Pelvic fractures can be suspected by identification of ecchymosis over iliac wings, pubis, labia or scrotum. Thoracic and lumbar spinal fractures and or neurological injuries must be considered based on physical findings and mechanism of injury. Patients back should also be examined to rule out any injuries.

Neurologic

Motor and sensory examination of extremities and reevaluation of patient's level of consciousness and pupillary size and response should be done. The GCS score facilitates detection of early changes and trends in neurological status. Early consultation with neurosurgeon required for patients with neurological injury.

Adjuncts to secondary survey

Specialized diagnostic tests may be performed during secondary survey to identify specific injuries. These include additional X-ray examination of the spine and extremities, CT scans of head, chest, abdomen and spine, contrast urography and angiography, transoesophageal ultrasound, bronchoscopy, and other diagnostic procedures. These specialized tests should not be performed until the patient has been carefully examined and hemodynamic status normalized.

Re-evaluation

Trauma patients must be re-evaluated constantly to ensure that new findings are not overlooked and to discover deterioration in previously noted findings.

Definitive care

May involve transfer to radiology/operating room/intensive care. Inter-hospital triage criteria will help determine level, pace and intensity of initial treatment of multiply injured patient. These criteria take into account the patient's physiological status, obvious anatomic injury, mechanism of injury, concurrent diseases and other factors that can alter patient's prognosis.


  Summary of Recommendations Top


  • Co-ordinated, comprehensive, systematic, organized management in the early hours is essential to improve the mortality rate in polytrauma victims. It should be mandatory that all patients with polytrauma be examined by the resident physician, surgeon, anesthetist, orthopedic resident and a gynecologist for female patients who co-ordinate for definitive plan and management.
  • Rapid primary survey (ABCDE) should be done with simultaneous treatment of life threatening injuries.
  • Manual inline immobilization of the cervical spine essential during maintenance and introduction of definitive airway in patients with suspected cervical spine injury.
  • Control of bleeding and rapid replacement of lost intravascular volume is essential. Warmed i.v. fluids should be used for resuscitation to prevent hypothermia.
  • Rapid neurological evaluation should be done including GCS.
  • Trauma patients must be re-evaluated constantly to ensure that new findings are not overlooked and to discover deterioration in previously noted findings.


 
  References Top

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2.Gennarelli TA, Wodzin E. The Abbreviated Injury Scale 2005, Update 2008. Des Plaines, IL: American Association for Automotive Medicine (AAAM); 2008.  Back to cited text no. 2
    
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4.Stewart RM, Myers JG, Dent DL, Ermis P, Gray GA, Villarreal R, et al. Seven hundred fifty-three consecutive deaths in a level I trauma center: The argument for injury prevention. J Trauma 2003;54:66-70.  Back to cited text no. 4
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6.Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. Delayed or missed diagnosis of cervical spine injuries. J Trauma 2006;61:150-5.  Back to cited text no. 6
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9.White AA 3 rd , Johnson RM, Panjabi MM, Southwick WO. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop Relat Res 1975;109:85-96.  Back to cited text no. 9
    
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12.Crosby ET. Tracheal intubation in the cervical spine-injured patient. Can J Anaesth 1992;39:105-9.  Back to cited text no. 12
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14.Rosen P, Wolfe RE. Therapeutic legends of emergency medicine. J Emerg Med 1989;7:387-9.  Back to cited text no. 14
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  [Table 1], [Table 2], [Table 3]



 

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